Saturday, January 06, 2007

Sedative Drugs Used in Pediatric Dentistry

Most kids do quite well without any kind of extra medication to accomplish treatment. However, sometimes medications are needed to help kids to be comfortable and cooperate to accomplish extensive treatment. After training and a lot of experience, I use this valuable method of providing treatment nearly every day and am confident in the use of medications to relieve discomfort, reduce anxiety and provide a safe environment through concious sedation.

There are just a few medications used for Conscious Sedation in Pediatric Dentistry. I emphasize Conscious sedation. That means the patient is awake and responsive but sedated. However, if administered improperly any of these drugs can put the patient into a deeper sedative state than is desired. In fact, due to the "Bell Curve" effect, even if done properly you can have a more profound a sedation than desired. This is not just a little valium given at home (which can help), but if we need a more profound sedation, something else may be needed. In addition, the Bell Curve (and experience) tells us that the same dosage that works well for one child may be like giving a drink of water to the next. It doesn't phase them at all. In fact, that is a more common result than you would think.

Basically, what you are trying to accomplish with sedative medications is a more cooperative patient with less movement so you can get the treatment completed, reduce any anxiety, and provide pain relief and comfort. Now it doesn't always work the way you hope, but you do try and find the best combination of medications tailored to each patient's needs.

Most of the time these are administered orally. Now, I know they are more predictable IV, but if you could get an IV started in an extremely uncoperative child, then you could do the work without the drug. In addition, liability insurance rates and certain state regulations make it somewhat impractical to use these parenterally (IV or IM). So most of us are stuck with the oral route. I know there are some who do IV, but they usually employ an anesthesiologist to come to the office. If you do that you might as well go to the Hospital (imop). In fact, if there is so much work that it will require several sedative appointments, then the option of general anesthesia is usually discussed. The drugs are usually liquids of course, as kids can't take pills well. It is important to dispense the medications accurately. We use this syringe from Baxa, it works quite well. It can be difficult to administer the meds because, again the child is uncooperative almost by definition.

Baxa Syringe:
Once you get it down you have to wait a while (about an hour for most meds) to get a clinical effect, then it only lasts for a while. These drugs are often used in combination with each other so you get the complimentary benefits of each drug without getting too high a dose of any one drug. You have to be aware of the additive effect of combining drugs. Beleive me if there were a better way, it would be used in a second. I want to emphasize that it takes lots of training education and experience to use these medications properly. Safety is of the upmost importance. Of course you have to monitor the patient and all procedures are done in accordance with sate law and AAPD guidelines. Which combination of medications to use is as much an art as a science. Ok, I know this is a limited list, but here is what I have read most Pediatric Dentists use most often:

Chloral Hydrate. A sedative hypnotic. Makes you sleepy. Sometimes used by physicians when doing a CAT scan or MRI. (See the blue bottle cap that fits into the syring above).













Meperidine, brand name DEMEROL. A narcotic that produces sedation and releives pain:













Midazolam, brand name VERSED. This is a very useful drug which is primarily an anti-anxiety agent, produices retrograde amnesia, and is a muscle relaxant and reduces the chance of seizures. Short acting (great for short procedures):













Hydroxyzine, brand name VISTARIL or ATARAX. Hydroxyzine is a milder medication. Primarily an anti-histamine. Is often used in combination with other medications:









Other drugs include Phenergan (That's what they give the astronauts before launch to prevent space sickness), Valium, or just regular pain medicine administered before treatment. On older patients you might use Ativan. I want to make a special note that some Pediatric Dentists have an anesthisologist come to their office and they administer general anesthesia using a variety of medications. One unique one is Ketamine, which is technically a general anesthetic with the patient all the way asleep, but they retain the ability to control their airway.

More here: Sedation in Pediatric Dentistry
Laughing Gas (Nitrous Oxide)

81 comments:

KK said...

Hello,
I'm a mother of a 4 yr. old who just visited our dentist for some fillings. I'm very consistant about our dental care but this was his 1st visit for cavity work. My son had a high level of anxiety before, during & after and with no success of having the fillings completed. We barely made it for a temp. filling. We tried laughing gas and he wanted no part, so my dentist prescribed Visteral 25mg/5ml for a future appt. to be taken 1 hr. prior to his visit. Since I've never had to go this far into dental sedations and after reading yours & other's websites, I'd like to know if my son should be monitored mechanically ( i.e., pulse/heart)while having his fillings done. Is monitoring standard/required for when it's a concious sedation? My dentist seems to get irritated when I question his level of knowledge, etc. I know I should probably find someone else, but I'm limited due to location in the country and don't want a dentist that's an hour away if needed. Thank you for your time.

Dr. Dean Brandon said...

Again, I cannot give recommendations for your child here, but generally Vistaril is a pretty mild, dare I say safe drug. Monitoring is in accordance with the American Academy of Pediatric Dentistry's recommendations. Usually a pulse oximeter is not necessary for minimal sedation, but each case is different. Minimal sedation usually only requires observation and intermittent assessment of the level of sedation. Only when/if they slip into a moderate level of sedation would mechanical monitoring methods be indicated.

You actually might want to be prepared that your child will still be fussy even with the Vistaril. If that is the case, I would suggest a Pediatric Dentist if possible so they can assess the situation. Of course I would recommend that anyways, but I understand your situation as you have explained.

Heather said...

I have a 5 year old whose pediatrician has suggested she may have a tooth enamel defect because of her severe tooth decay despite FREQUENT tooth brushing (3-5x per day--I brush them morning and evening, she brushes after lunch and snacks). She recently developed 2 abscesses in the top teeth, 1 on each side, 2nd tooth from the back. Her dentist wants to extract them and all 4 lower molars. He gave her an antibiotic and said to return in 4 months for treatment. 2 days after she was done with her antibiotic, her fistulas started growing again and she is complaining of toothache. I called and he now wants to perform the "treatment" (all 6 extractions) tomorrow, using versed for sedation. My question is: is it safe for her to have the extractions while the infection is present? Also, we brush and use the little flouride flossers for kids, is there something else we should be doing to prevent her decay as it is SEVERE and her younger sister seems to be following in her footsteps. Is there a treatment we should seek for her?

Dr. Dean Brandon said...

Here is a quick response (as you said you have scheduled tx tomorrow):

--antibiotics help, but do not cure dental abscesses, usually the abscessed teeth should be removed or else the problem may return.

--sedation is often indicated for dental treatment and if done properly is a reasonable methodology.--read my posts on sedation to get a better idea on that.

--sometimes you can brush all day long and there still may be decay due to factors beyond our control. Early treatment and examinations (even at one year of age is not too soon) are better than waiting till the problem gets too far along.

--don't take my "internet" word on this, ask your own dentist.

Heather said...

Dr Brandon--You just answered my prior post, one more quick question: at 3 pm snack time I noticed nothing abnormal, however, at 5 pm I noticed my daughter's lower jaw was swelling but her known abscesses are on the top of her mouth--when do you just wait to see the dentist and when do you classify this as an emergency?

Dr. Dean Brandon said...

I can't tell you what to do, but a really large amount of swelling (that causes airway restriction) can be an "emergency" --the vast majority are not. Sounds like you are seeing him tomorrow anyways?...If it's really bad, call him (or go to the emergency room).

I've got to run, but Good luck!

Anonymous said...

Hi,
My daughter is 4 1/2 and needs several fillings. She's had one without any pain medication, but it did cause a little discomfort. The dentist is planning to give her an injection before the next one. My concerns are these: what will he be using, and most importantly, there is a family history of malignant hypothermia on her father's side. Are any of the drugs he will be using triggers? He is aware of the condition, though made no comment when I addressed my concerns other than "Everything will be fine. I'll see you in a few weeks" This is the second dentist I've been to and neither seem to be taking my concerns seriously. There are only 2 dentists in my area. There are several more 4 hours away, but travelling is very difficult at this time. I would appreciate any feed back you could give me on this matter. Thank you.

Dr. Dean Brandon said...

Sounds like you are talking more about a local anesthesia injection like lidocaine to "numb" the area. There are concerns with malignant hyperthermia with general anesthesia. How all this applies to your situation I cannot say. Caution should always be used with drugs especially drugs used for sedation. If the injection is something to "sedate" her, I would try and find out more.

Anonymous said...

Hi,
My 5 year old son has to have a tooth pulled, space maintainer put in, pulpotomy done, and a cavity filled. They are going to sedate him using Chlorahydrate, demoral, and phenorgan. How safe are these? Because I am terrified about letting them do this. They are also going to be giving the laughing gas, but didn't feel that would be enough. Is this the normal procedure for someone his age? Thanks for your help, any advice would be great! Thanks.

Dr. Dean Brandon said...

As you can see from this post these drugs are used quite often. I use the ones you mentioned every week. What is best and safest for your child cannot be determined by simply which drugs to use. Every child and every situation is different. It is good to be as informed as possible, but be prepared for the unpredictable. Good Luck.

Anonymous said...

Hi,
My five year old son is having surgery on Tuesday to remove his upper front baby tooth and the impacted extra adult tooth beneath the gumline. The dental surgeon requested permission to have this procedure done under anesthesia in a hospital, but the insurance company denied the claim, stating that their policy is to have children over 48 months be treated for this type of issue under local anesthetic in an office setting. I am appealing the claim and am hoping you can point me to any information you have about a child's age and sedation. Do you know of any references, research or guidelines about what is appropriate for a five year old? Thanks!

Dr. Dean Brandon said...

I see insurance companies once again deciding where and how to treat patients. If they think it is best in the office setting, let THEM (the insurance companies ) come in and do it themselves! They obviously think they know what is appropriate. They really have no idea how to treat children and that children really are different than adults. Realize they are ONLY considering their bottom line.

What I am saying is that I sympathize, but it is something I have seen before. Unless the patient has some sort of significant disability like cerebral palsy, you are not likely to get them to "change their minds". It is a pattern I see too often with 5 yrs and up--bet it's Blue Cross too. If there is something I come across I'll post here, I'll also ask our coordinator for advice as she handles this kind of thing for us. Good Luck.

ljmpenny said...

My daughter just underwent general anesthesia for what I thought was going to be cavity treatment with filling and clear plastic sealants. She had 3 extractions(upper molars) and 6 crowns put in on her molars. She threw up alot, we left hosp. at 1:00pm and she was still vomiting afterwards till 9:00pm. Was this too much work done at one time? She was under gen. anesth. for about 4 hours. This was 4 days ago and her jaw is still sore and she hasnt eaten solid foods yet. I feel this is too much done at once for a 7 year old. Is this normal?

ljmpenny said...

ps- regarding my last post, about the extractions, I forgot to mention, that my daughter said her teeth didnt hurt and had never hurt her before. If she had no pain, then why extractions? I was hoping you would have a specific post dedicated to extractions. Maybe next time. Thanks for any response.

Dr. Dean Brandon said...

The gases and medications used in general anesthesia can cause nausea afterwards. I think that is fairly common. If you are concerned about the discomfort, I'd contact your dentist.

Larisa said...

Dr. Brandon,
My daughter is 4.5 y old and she needs 4 fillings and 2 baby root canals to be done (all for molars). At 1st we tried to do it without sedation, because she was very cooperative during regular check-ups, but it looks like her fear of drilling (even its sound) was stronger than her desire to cooperate... So now I'm trying to decide between sedation and general anesthesia. The thing is that she is very emotional and sensitive and very active. She had allergic reaction to dimetapp (became hyperactive) and some complications after DTP vaccination (wasn't able to sleep for several days), when she fall asleep she always need TO TUMBLE a lot. To your opinion, what type of treatment should I choose for her: general anesthesia or conscious sedation ???
Thank you very much beforehead,
Larisa

Dr. Dean Brandon said...

Larisa,

I cannot advise on specific treatment..

In general, the more treatment needed, the younger the child, the more "head strong" the child is--I am thinking general anesthesia. Still, much can be done with conscious sedation which I do nearly every day. These kinds of decisions rest with your pediatric dentist and you based on the child's specific situation.

Anonymous said...

Dear Doc:

What are the risks for having my 9 year old be sedated with Versed for dental procedure at a Children's Hospital environment where an anetheisologist does the procedure for the dentist? They recommend have her tubed during the procedure even thought they state she would breathe on her own? Is this really necessary?

Dr. Dean Brandon said...

A hospital environment is one of the most controlled environments for any medical procedure.

Dr. Dean Brandon said...

Anything we do is in accordance with AAPD guidelines on conscious sedation. I agree it would be nice to use IV titratable sedative medications with an anesthesiologist present. If we feel it is indicated we usually do cases in the OR at he hospital, a much more controlled environment. There are several barriers to IV in-office sedation:

1. It is difficult to start an IV on a disruptive young child.
2. Liability insurance rates are much higher and the laws different for IV sedation (depends on the state)
3. To account for the increased costs involved in having an anesthesiologist present and taking into account other cost and insurance, it can become cost prohibitive for the patient. For instance, the cost of doing the sedation alone could be many times the cost of the actual procedure.

Now, I do know of instances where this(in office IV/inhalation with anesthesiologist) is done with some practical success, Florida comes to mind. Each state is different.

Dr. Dean Brandon said...

Anything we do is in accordance with AAPD guidelines on conscious sedation. It is not the case that we are not aware of alternative techniques. I agree it would be nice to use IV titratable sedative medications with an anesthesiologist present. If we feel it is indicated we usually do cases in the OR at he hospital, a much more controlled environment. There are several barriers to IV in-office sedation:

1. It is difficult to start an IV on a disruptive young child.
2. Liability insurance rates are much higher and the laws different for IV sedation (depends on the state)
3. To account for the increased costs involved in having an anesthesiologist present and taking into account other cost and insurance, it can become cost prohibitive for the patient. For instance, the cost of doing the sedation alone could be many times the cost of the actual procedure. If you get into these large costs, it is often more reasonable to do it in the OR.

Now, I do know of instances where this(in office IV/inhalation with anesthesiologist) is done with some practical success, Florida comes to mind. Each state is different. I fit were practical, believe me we (pediatric dentists) would use it more.

Anonymous said...

Dr. Brandon,
Is it safe to give children Valium at home? I am looking for a dentist to treat my child's cavity. One said they will give me a prescription for Valium to give my son at home before the visit. However, the other one said this is dangerous and that they cannot give my son Valium even in his office, because they do not have a hear-monitor.

I am confused, one considers giving Valium even at his office to be risky, while the other tells me to give it my son at home. Obviously, I do not have a heart-monitor at home.

Dr. Dean Brandon said...

There is always a risk with any medications. Some would say giving anything at home is not advisable. As Valium at appropriate doses given in an appropriate manner is relatively safe, we often will prescribe valium at home prior to an appointment to relieve anxiety. Again, it depends on the patient, medical conditions, other medications, and state laws as well. Heavier drugs should not be given at home, but should be administered in the office if appropriate. Not advice, Just my opinion.

Anonymous said...

My daughter when she was 4 had to get an abcess tooth pulled. The pediactric did a consious sedation with by a nasal thing. We were not allowed in the room but we could hear her crying or screaming the whole time. She could't remember any of it but is that normal for her to be screaming. She has to get an impression for her spacer since it was her 2 year molar and her 6 year molar is in. She is 5 1/2 and they want to sedate for the impression so she will be still. I don't understand how she will be still if she was sreaming the last time. what do you think.

Dr. Dean Brandon said...

Anon--some kids scream just walking into the room. Some kids hop right up and no premedication is required--you can just do about anything. If premed was recommended, it is likely to help the child cooperate, be more comfortable and allow better work to get accomplished. Most kids become more cooperative as they get older.

Vicky said...

My son will be 7 in a few months and needs a pulpotomy and then a crown over top. They are giving him 1 ativan to take a half hour before. Is this ok for him??

Dr. Dean Brandon said...

Ativan is kind of like Valium (in the same family of medications). I don't usually use that on children, but more so on the adults. I know a lot of general dentists use that with adult patients. I cannot say if it's ok or not. It is a good medication to relieve anxiety.

Anonymous said...

Hi,
I have a 4 year old son that need a root canal on a cavity on his back molar. He was very good for his first time at the dentist but she recommended he have valium before the procedure next week. I am very worried about giving him this medication but when I asked her more about it she just said that althought some of the pharmasist discourage mothers from using it, it is safe and the best thing for him. I'm really not sure what to do

Anonymous said...

Hi,
I have a 4 year old son that need a root canal on a cavity on his back molar. He was very good for his first time at the dentist but she recommended he have valium before the procedure next week. I am very worried about giving him this medication but when I asked her more about it she just said that althought some of the pharmasist discourage mothers from using it, it is safe and the best thing for him. I'm really not sure what to do

Dr. Dean Brandon said...

We use valium often, but only when indicated and at proper dosages.

Anonymous said...

My 4 yr old son is about to get some caps on his teeth and fill a cavity. I am SO scared and nervous about it because he will be getting sedated with Demerol. Is this relatively normal or should I try to see if they could do it with no sedation and just laughing gas to relax him? Am I being too over reactive here? Thank you for anything you might say.

Dr. Dean Brandon said...

I used Demerol often, but only when indicated and under strict criteria. Sometimes other meds are better. Sometimes no meds are needed at all. Ask your dentist and get as much info as you can. It may be that a certain patient cannot cooperate with just laughing gas alone. Every case is different.

Anonymous said...

I have a 5 yr old daughter who went this week for one of several treatments needed. She had a cavity filled, and needs 3 crowns. The problem is we went to the local Dental College, and they gave her Happy Gas, and a local, after numbing her gums. I am not convinced they waited long enough, and during the procedure, she lost her mind, kicking her legs, screaming, and pulled everything out of her mouth. Luckily she didn't pull out her tooth. The instructor had to put her in a head lock, while I sat and held her hand, and she got the filling in. As for the crowns, she said they were not going to be able to treat her at the Dental College, because she needs to be sedated. Now after watching all of this, I was freaked out, and have no problem with her being sedated. The only issue is we have no dental insurance, that was why we were going to the Dental College. The local Children's Mercy Hospital in KCMO, is booked and I cant get her in there, and another low income dental clinic has a 2 yr waiting list for children who need be sedated for dental procedures. I called to get her a dental insurance policy, and they have a 12 month waitng period before they could do what procedures she needs. I am worried that her teeth will continue to decay and get to the point where I have to take her to the emergency room. We do have health insurance, through TriWest, and Monday am going to call them to see if since she has to be in a hospital situation they would cover it. But knowing how our run in's with TriWest, I am sure the answer is no. So what am I to do. I don't have a problem making payment arrangements with a pediatric dentist, if they are willing to work with me, because the feeling I got from the Dental College staff is that they need to be taken care of immediately. Do you have any suggestions as to where I could take her? I have thought of taking her to Children's Mercy dental clinic as a emergency situation, but am not sure if they will consider it to be a emergency.I am at such a loss and have no idea what to do now.

Dr. Dean Brandon said...

Firstly, there are many children that pitch a giant fit as you discribed and it is not unusual for the decision to be made to use either sedation or general anesthesia to complete treatment. Decay does get worse with time. The main disadvantage to waiting is that more extensie treatment may be needed and of course eventually thay may abscess. That actually is easier to treat (remove the tooth) than a fancy crown or even a filling. Dental (and health) insurance still baffles my as to why they cover (or not) certain things--generally whatever saves them money. Medicaid does seem to cover general anesthesia cases and some state assisistance programs are available (here it is called Al-Kids) for those just above the medicaid income level. I sympathise, but do not have great suggestions, but sounds like you are a caring parent and I bet it will all work out for you. Perhaps one step at a time.

Kay GRacie said...

Hello
my daughter has had teeth since 16 weeks and visited dentist regulary. However last visit the dentis saw the start od tooth decay on side teeth (same on either side) said she grinds her teeth. The two teeth have a brown smudge ontop that cannot be removed by brushing - we have been prescribed fluoride tablets. Can you tell me if this will help stop further decay on the discussed teeth? I wish there was something I could do to help her - I brush them regulary and watch her diet but the though of her going in for treatment is really worrying me.

Any advice?

Kay

Dr. Dean Brandon said...

Well, if it is a cavity, brushing will not make it go away, and it will continue to get worse. A filling or something may be indicated. Fluoride helps prevent new decay from forming on unaffected tooth surfaces, and sometimes slows active decay down a tiny bit, but basically, you still need a restoration if there is actual decay there or it will continue to get worse.

Donna W. said...

Dr. Brandon,
I don't know if this post is still active, and if you still monitor it or not, but I thought I would give it a shot. My 8-year old has a cavity. We have tried 2 times to have it filled unsuccessfully due to his large amounts of anxiety. Nitrous made him "feel weird", and he fought it off, so it didn't help. We have now been referred to a pediatric dentist. She uses Versed if Nitrous is a no-go. Will we have the same problems with Versed? If he starts feeling the effects, will he be able to fight it off? He has had his tonsils removed and has such fear of being put to sleep again, but we have to get this cavity fixed!! Also, how long does it take for the Versed to take effect? Thanks so much, hope you get this post. Donna.

Dr. Dean Brandon said...

I use Versed all the time. Just like any other medication, you never know exactly ahat you are going to get. Nitrous is great but sometimes pretty wimpy. There are other medications as well. Check out my other posts on sedation as well. Good Luck.

Pearl said...

Hello
I have a 5 year old daughter who is terrified of dentist and on her last visit were were told that she had a baby root canal and a couple cavity. The dentist suggested using demoral. I was wondering if demoral is as or stronger than versed? Will it put her to sleep? Will she still be aware of the work being done?

Dr. Dean Brandon said...

I would discuss medications and your expectations with your pediatric dentist. Most medications do not put children to sleep (meaning unconscious). The hospital is usually the location for general anesthesia (completely asleep). Most dentists use medications to relax the patient, alleviate anxiety, increase cooperation, increase available working time and provide comfort. Medications are not necessarily more or less strong than each other, they are different in their effects and dosages. I pick and choose which medication(s) to use based on many factors. Please read up more on behavior and sedation in the dental office here on the blog. Good Luck.

Anonymous said...

My daughter is 18 mths old and has to have a pulpotomy due to a fractured tooth. The dentist mentioned a papoose to help restrain her or I could have her put to sleep. Both options make me nervous. What are your thoughts on the papoose and what option do you feel would be best?

Dr. Dean Brandon said...

An 18 month old (or for that matter most two and three year olds do not have the ability or inclination to cooperatie for dental treatment. Holding hands or some other kind of restraint is often necessary just to take a look in there. If restraint bothers you, you may want to discuss options of sedaton, general anesthesia, or no treatment at all. I have never found an adverse problem with a papoose other than the parents feeling in some way bad. Young children, especially "head strong" kids do not like to do anything they do not want like being still, therfore there is often lots of drama there. Also, if the papoose bothers you particularly, consider just having the staff (and or you) hold them during treatment. I know it's a hard thing when choices seem limited. Feel free to peruse the other related topics in this blog.

Melissa said...

Hi! My daughter is 2 1/2 years old and just went to have her first cleaning a month ago. The dentist found three cavities in her fron teeth. My daughter did amazing throughout the entire cleaning. She was very well behaved and not scared at all. My concern is that the dentist (who was only in the room to look at her teeth after the cleaning) suggested conscious sedation to fill the cavities. I am really concerned that the dentist is not giving my daughter the opportunity to even try to have the cavities filled without sedation. I know she is young and that is my main concern for not wanting her to be sedated. I have asked the dental office to try and fill the cavities without sedation but they told me that the dentist usually won't go back on her recommendation. I do not want my daughter sedated and I just feel like I have no options. The pediatric dentists in my area are very limited. I guess my questions are, is it right for the dentist to be so quick to judge my daughter? Can dentists try to fill cavities on young children without sedation? And by waiting to have the cavities filled how much am I hurting my daughter? Thank you!

Dr. Dean Brandon said...

You can always decline treatment recommendations, but waiting has it's consequences as well,--like the problem can get worse and require more extensive treatment later on.

Decay on two year olds is always a dilemma. We want to get the work accomplished, we want the child to be comfortable and not cry or fuss, we want the child to be still for treatment and we want to do all this without any medication or restraint. That's a tall order as two year olds do what they want to do not necessarily what we need them to do.

Most two year olds are not going to cooperate for dental treatment. In fact most cry just to lie down and take a look. As pediatric dentists we see many many kids of all ages every day. Through experience we have a pretty good idea what the best thing to do would be. We know what the procedure involves and how patients could and often do react. If a two year old has any kind of treatment that may require more technical precision, you need the child as still and cooperative as possible. What if things are going well, but half way through he procedure the child becomes upset and resistant? So, often sedation is recommended. General anesthesia is also sometimes considered especially if the work is more extensive. Now there are drawbacks to sedation expecially in young children as I have written before.

One thing to consider is what is the goal. Remember this is surgery.

There are rare occasions where the choice is not to use sedation--almost always it is a short procedure that does not require much precision. Holding hands and restraint is often needed.

In the extreme, it's sort of like if a child needs an appendectomy and the recommendation is to use general anesthesia to remove the appendix. Yes, you "could" do the surgery with only local anesthesia, but would you want to take the chance on excessive or unexpected patient movement causing a problem? That's why docs recommend general anesthesia.--by extension it is why dentists recommend sedation or other modes to help alleviate discomfort, movement, and generally help the child have a more pleasant experience while accomplishing the treatment.

Feel free to read more here on these subjects.

Joshua said...

My son is two years old and is have a strip crown done in the morning, how safe is valium at his age?

Dr. Dean Brandon said...

No drug is totally safe, no drug is totally unsafe. Each case is different. I will say we use valium often for anxious patients-usually older ones. It tends to be pretty wimpy on two year olds as far as behavior control (in many cases). btw-(most drugs are kind of wimpy on two year olds)...read my posts on sedation and behavior management too..and ask your doctor. good luck.

Vicki said...

Hi Dr. Brandon,
My son is almost 4 yrs old, easy going and needs to have two baby root canals on his molars and crowns. The Ped office in Southern California has an in office anesthesiologist for IV sedation. He uses Ketamine in the shoulder (3-5 min) to get them drowsy and then puts in the IV and administers Propofol for the sedation. What is your opinion of these two drugs? Thank you Vicki

Dr. Dean Brandon said...

Ketamine and propofol are definitely major league medications--that is, they are general anesthetics. They are not used for conscious sedation only general (all the way asleep). So, if someone is trained to administer them properly and have the proper monitoring and backup required for general anesthetics (like at the hospital), they are great drugs if they are indicated. In our practice, we do all general anesthesia cases in the OR at the hospital. There are practices that use an anesthesiologist in their offices. The regimen you mentioned makes some sense to me so long as they are qualified. I cannot say it is the best for your child as I do not know the circumstances.

Anonymous said...

My 9 year old daughter was kicked in the mouth while playing with other kids about 3 weeks ago.

She has seen our regular dentist and then a pediatric dentist and then an endodontist.

She has been taking amoxicillin (250mg 3 x day for 10 days).

At the endodontist, when a COLD cotton swab was placed in contact with the subject tooth (permanent no. 9 front upper tooth), my daughter could NOT feel the COLD sensation at all.

In contrast, her "unhurt" teeth were EASILY able to transmit the COLD sensation to my daughter when touched with the COLD cotton swab.

Accordingly, the endodontist has recommended a root canal below the horizontal break (in the tooth at the nerve break -- per x-ray) for the subject damaged tooth.

In doing so, what is the safest way to alleviate pain and discomfort for my 9-year old daughter?

What anesthetic is safest?

What anesthetic to avoid?

I am concerned about "over medicating" a 9 year old -- but at the same time -- I "wish" my 9 year old daughter to be as comfortable as much as possible -- however (most importantly) "without undue risk" to her overall health and safety -- given her young age.

The endodontist is going to remove any infected pulp and fill it in with calcium hydroxide or something like that (can you clarify please?).

I have read that the success rate is 90% for this kind of "root canal" procedure to save the tooth.

Are there any particular concerns regarding the anesthetic to be used, how much, what is best recommended course of therapy -- in a generic sense -- and -- what should we look for?

I have myself 10+ years ago been treated for a root canal followed by post and crown with no difficulty from the same endodontist office -- though by another member of the group.

But I was an adult when I had my root canal; whereas my anxiety stems from the fact that my daughter is just 9 years old for such a "root canal" procedure necessary to save her tooth and to avoid a worse infection if not so properly treated.

Any and all of your comments before Wednesday of this week will be appreciated.

Please

Dr. Dean Brandon said...

Sounds like you have lots of questions. I am not an endodontist, nor can I comment specifically about your case, but Calcium Hydroxide (like a powder or paste) is used to fill traumatized teeth to prevent external resorption of the tooth (sort of like rejection by the body). Later on they usually fill it with the regular gutta percha filling material.

Sounds like they are plannign some sort of sedation for your child. You can read here that sedative medications is as much an art as a science. I use sedatives almost every day on children as young as two years old. What is best? Ita all depends. A "root canal" is no more difficult for the patient than any other detnal procedure other than it takes a while.

Margaret said...

Hello Dr.
i came home tonight from work and my 18 month old came running and smiling at me i picked him up and gave him kisses and noticed something so very upsetting his four front teeth were chipped beyond belief. I immediately questioned my husband and other children and they said he was chewing on pebbles at the park this evening. oh my Goodness i started crying, my son had beautiful white, perfect, teeth and now they are almost gone down to the gum...i am in fear of sedation because of his age but i have to get him to childrens hospital dental dept to get him treated asap but hypothetically speaking if i brought him to you with this issue what would you recommend, just so i have an idea of what to expect. and by the way i did question how no one noticed he was putting pebbles in his mouth..Please can you please just give me an idea of what to expect. Thank you for any help.im lost and need answers and dont want to wait.Margaret

Dr. Dean Brandon said...

Sorry to hear that. I cannot tell you what I would specifically "do", but--Kids will find a way to chip their teeth. If it is really as bad as you indicate, I suspect he fell-either way, short general answer: Small chip-smooth it off or leave it alone and observe, medium-possibly a white filling to restore the tooth, large fracture-restore if possible with filling or crown or remove the tooth if damage too extensive. If it's really involved treatment, general anestheisia might be needed. Most treatments are not too involved though. Good luck, I am sure it is not as bad as you might imagine right now.

theresa said...

I have a 22 month old with 4 cavities and I am trying to decide between outpatient general anesthesia or an office visit with mild sedation and a board. In your personal opinion does a very squirmy screaming child make it more difficult to do "good" work? Also, at what age or weight can a stronger sedative be given. I am told that what they could give him wouldn't really do a whole lot.

Thanks!
Theresa

Dr. Dean Brandon said...

Theresa,
Often very young children require a lot of medication to become cooperative enough for dental treatment-which for a two year old is basically asleep. Sometimes that is too much medication to be safe in an office environment. A squirmy sedated child does make it more difficult, but not impossible. If it is too difficult to do good work, I usually stop or try something different.

Your Pediatric Dentist can give you guidance on reasonable options. If there is a lot of technical or more difficult procedures, or just a lot of stuff to do, I lean towards GA. It is easier (most of the time) to adequately "sedate" a child of four years old, than two.

Anonymous said...

Hi Dr. Brandon,
I have a ten year old son with autism and we are in the process of having him go to the dentist. He has severe anxiety over any dental work and we have had to have him under GA to achieve some cavity filling when he was younger. Now we are looking at oral sedation and were trying to get a feel of its effectiveness and safety. Can you give us some helpful info in regards to this delemma? We are hoping to get him in for a simple exam and cleaning along with potential x-rays. Thank you for you advise.
RB

Dr. Dean Brandon said...

Anonymous.

It is interesting you bring up Autism. I am actually working on a brief post on the Autistic dental patient. It should put it up an a week or so.

Basically consicious sedation can be a great adjunct to treatment of the Autistic child. Yes, sometimes general anesthesia is more appropriate, but just as wiht all children that have a hard time cooperating, or have lots of dental work, or lots of anxiety, conscious sedation can be one way to help them get the dentistry they need. There are of course, the regular behavior managment techniques that can be helpful if sedation is not indicated. That would be most appropriate for brief easier procedures or on patients where that seemed the best thing to try. Like I have often said, each case can be different from the next.

Anonymous said...

I can't believe I just received a bill from my pediatric dentist with 2 charges one for $22 laughing gas and one fo $83 sedative. Neither of these are covered by insurance and I must say $83.00 seems extremely high for a small cup of liquid sedative! I'm not happy about this. Seattle, WA

Dr. Dean Brandon said...

Fees for things like that also take into account the liability of handling and administration of drugs as well as monitoring equipment and staffing, etc. Actually, sounds like those fees are even on the low side. Certainly, non coverage by insurance would make anyone mad. Often, conscious sedation is not covered by insurance. Fees for general anesthesia can run thousands.

Dr. Dean Brandon said...

BCG asks: "Is it common to sedate a 4 year old with 50mg of demerol to repair cavities? " There are many four year olds that weigh a lot and some do not and dosage id often calculated based upon weight. Demerol is used for children of that age usually in combination with other meds. The usual dosage is 1mg /kg. It can be higher, up to 2mg/kg if used alone or with milder drugs like Atarax. No matter the weight, I personally do not go over 50mg.

Dosage is also dependant ot behavior and the procedure comtemplated and medical conditions. Oral dosages are often higher than IV for narcotics due to first pass metabolism in the liver before it ever gets into the bloodstream. In addition, IV dosages are much lower for the same behavioral response. So, there is not a yes or no answer. It is important to not overdose. If you are unsure, ask your pediatric dentist. Any medication in children should be given in accordance with the Academy of Pediatric Dentistry guidelines, and in my opinion by a specialist in Pediatric dentistry who has experience in using sedative medications in children.

Jessica said...

I don't know if the questions are still being answered, but I thought I would try. My son is supposed to go in for a couple caps and a filling tomorrow. They want to concious sedate him. What I wanted to know is he has had a cold. All he has right now is a stuffy nose and it hasn't escalated from there. I called the dentist's office and let them know and the lady told me that they would check his lungs before they started to make sure they were fine and if anything looked wrong then we would reschedule. Would it be best to re-schedule his appointment or go forward with it since he only has a runny nose? Thanks!

Dr. Dean Brandon said...

Jessica, we advise our patents to reschedule if a child has a cold or fever. I suppose they would evaluate his airway and health prior to sedation. It is very important to have a good airway. Sometimes it is ok if it's just a slightly runny nose. All that can be evaluated the day of treatment, but sometimes you can just tell that it's best to eait. Ask your dentist.

Dr. Dean Brandon said...

That is, best to WAIT. Sorry a typo there.

Anonymous said...

chloral hydrate! That tells me all I need to know about your training.

Dr. Dean Brandon said...

I'm glad you have such a profound knowledge...
This is a list of drugs often used by pediatric dentists. CH is not used in every case and only in appropriate dosages. Patient selection and evaluation and proper protocols and monitoring is what it's all about.

Anonymous said...

My son is 6 and has to have a tooth filled tomorrow am and the dentist gave him valium 5mg for 57lbs before we go, usually he don't use anything and my son cooperates like a trooper, is this ok I am really nervous about giving it to him it sounds like alot for a child..

Rwadh said...

My 3 yr 4 month old needs pulpotomy done on tooth S and L. I'm confused between Nitrous oxide and Sedation( i think office uses chloral hydrate and phenargan) . He is a very cooperative child. In you experience at this age, can they do good with nitrous oxide.

Dr. Dean Brandon said...

Read more here on the blog about Nitrous Oxide or Laughing gas. It's pretty mild but does help. I do not consider it "sedation" but light analgesia. To me sedation involving the drugs you mentioned is a more profound sedative. Still, as you can read here, there are a lot of variation in behavior. What procedure you are doing matters as well. A cooperative child for a cleaning or even a small filling might not be a cooperative for more involved procedures like pulpotomies and crowns. It's a judgement call for the dentist and parents.

There are three year olds that can do surprisingly well without any pharmacologic sedation, but it's not too many--or if they do well, maybe for not too long. All kids get tired after a while.

rwadh said...

Thank you Dr Brandon for your response . My child is very co-operative. the procedure he needs is pulpotomy . In your experience can a 31/2 yr old can do good with nitrous oxide.

Dr. Dean Brandon said...

I cannot say. A three year old can, but I don't see it that often. By the way, you may want to look up here on the blog "what is a pulpotomy."

snowflake130.52 said...

My 2 year old daughter needs to have extensive dental work. Her pediatric dentist told me that she would need to use chlorahydrate and phenergan in order to perform all of the work required for cavities and root canal and other treatments. I am nervous about having this sedation administered to my daughter but I am also nervous that if I wait until she is older, it may end up getting worse. Some people have also said that her baby teeth will fall out anyway, so I should just wait... but I dont know if thats a smart idea either.
Ultimately my questions are the following:

1. Is there many risks involved to administer chlorahydrate and phenergan to a 30 pound 2 year old?

2. Is there harm in waiting until she is older to have the dental work done?

Thanks.

Ling said...

Dr. Brandon, Thanks for maintaining such a good blog! As to sedation and anesthesia, what do you think of the following information? FDA is re-evaluating whether General Anesthesia is causing cognitive risks in young children.
http://www.nytimes.com/2011/03/10/science/10anesthesia.html

I talked to several pediatric dentist, they seemed to dismissed it right away!

Dr. Dean Brandon said...

I am aware of these studies. As of this time, there is still no evidence of any problem for shorter procedures, like less than four hours. Most dental procedures are less than 2 hours. Still, it's always of concern. We rely on anesthesia and physician professionals to get more data and make recommendations. So, far they have not seen anything to make a change at this time.

Anonymous said...

What about afer care ? My ten year old daughter needs a tooth pulled, what medication is prescribed after ?

Dr. Dean Brandon said...

If a child already has sedative medications on board Tylenol or Motrin is all that is usually needed for any post op discomfort. It may depend on what is done. A couple baby teeth are usually no problem. Even bicuspids are easy to care for. A large surgical extraction may need post op narcotics but you gave to adjust based on what premedication drugs were used. It's up to the doctor. You can ask them what they recommend in your particular case.

Valerie G. said...

Hi Doc,
My six year old had his first visit and everything went well. He has one cavity that will require a crown, and six back teeth that need fillings. I took him to MY old pediatric dentist, which was very neat by the way, and he did great! I had a lot of dental work done on my teeth when I was younger (milk-teeth) and my mom doesn't remember my dentist ever using conscious sedation...only the "elephant nose" (laughing gas). They didn't even have the freezing stuff so you wouldn't feel the shot. I can't tell you how many times I heard "Okay, here's the little bee sting." It never FELT little! Hahaha.
Still, knowing this and growing up with no fear of my dentist...I am now faced with the dilemma of being told I have to give my son Demerol before his procedures. I have asked that we try to have the procedure done without it first...and if it doesn't go well, then I'll use the sedative. Here's my question: Can I go through my son's pediatrician for sedation meds? I'd rather have her input since she knows his medical history a bit better...plus it might actually be covered under my insurance, since my dental doesn't consider it a necessity. What are your thoughts?

Dr. Dean Brandon said...

Valerie,

1. Most kids do well without any medications.
2. The procedures are not actually that difficult for the patient.
3. Some children do benefit from sedative medications.
4. A pediatric dentist would not give medications without reviewing the medical history.
5. It would be out of the ordinary I think, for the physician to prescribe medications, but not unheard of. Certainly if you have concerns with a medical problem consultation with the patients physician is ok.
6. Most pediatric dentist's fees are not based on the medication itself. If it's just a valium at home, then yes, the patient fills a prescription, gives it at home. However, demerol and like medications must be given in the office. Our fee for conscious sedation with the heavier medications like that is the same no matter where the medicine comes from. We provide the medications in our office. Any sedation fee is for the extra monitoring , staff, extra scheduling time, liability and finally the actual medications.
7. Some parents ask me the same thing, "can you try without meds first"? It is certainly the parents prerogative to decide what is done-or not, and rarely, the kids do surprisingly fine. However, if medication was recommended, there is a reason. If things do not "go well" then the second appointment attempt may have much less chance of success even with sedative medications, as anxiety levels would be higher. So, not usually a good idea. At least that is what I see often in such cases. I'd rather have a good first experience for a child with sedative medications, then later on, they may not need any medications at all, once they get slightly older and/or realize it's not such a big deal due to their good experience the first time.
8. Each child is different.

Anonymous said...

Hello,
My son is almost four and he has prescribed a procedure for left molar extraction and two right back teeth crown under IV sedation. he is a small baby like only 3 pounds and very small in height too. I am sooooo worried about IV sedation for him which is kind of general anesthesia any way.
He is alreafy delayed in speech and have sensory issues.How much Iv sedation have risks for somebody like him?Is IV is given by weight?The procedure would take place in office with anestheiologist team coming to the office.How long these chemicals would take take to be out of his system.Please help!
I am very stressful.

Dr. Dean Brandon said...

An anesthesiologist should know how to properly and safely premedicate a child for dental procedures. It is certainly a stressful situation. They usually base dosages on weight or something like body surface area and age, etc. Ask them if you have any specific questions.

Anonymous said...

When I got custody of my grandson he was 2 1/2 and had to have dental restoration under general anesthetic in a hospital. It was quite traumatic for him. He had one molar which required pulptomy & a crown along with many other caps/crowns. Now the molar is abcessed and will be removed along with 2 upper baby teeth due to crowding as recommended by the orthodontist. A spacer for the molar will be put in when it heals using Nitrous Oxide. Our pediatric dentist is sending him to an oral surgeon (so his pediatric dentist's office will remain a "happy place") for the procedure who will use Versed. My grandson is now 6. My concern is that antihistimines, Singular, even Zyrtec all make him hyper. What are the chances of Versed having the opposite intended effect on him? Also I had an abcessed tooth pulled before and it was quite painful even with novacaine. Wondering if the pain level will be as severe since it is a baby molar.

Dr. Dean Brandon said...

Usually an oral surgeon will administer whatever medications are necessary to achieve the desired result. We usually use Versed as an oral medication (as they do in the Operating room prior to general anesthesia), which works great most of the time, but can lead to unpredictable results in a few cases. The IV is better and can be used by some oral surgeons. If you can start an IV in an anxious child however, you usually can do the work without any premedication. Still, the oral surgeon can make adjustments to get him where he needs to be to be comfortable even if it means all the way asleep. Talk to the oral surgeon about what they are using if you have further questions.

I will refer patients to an oral surgeon for wisdom teeth removal and sometimes for other more routine extractions for patients who do not respond well (like they have a very high anxiety level not amenable to oral medications).

Dr. Dean Brandon said...

I am closing the comments for this post as I often do for older posts that have a large number of comments. There are over 80 comments at this point. There really cannot be enough discussion about this important topic, but as a blog post, what is here is very complete. God Bless.