Thursday, January 04, 2007

Sedation in Pediatric Dentistry

Most children do quite well for dental treatment. Remember every child responds differently in the dental office. There might be a three year old getting a filling doing just fine sitting next to a twelve year old who is extremely anxious or defiant. You can get them used to coming to the dentist with regular early visits. The children get used to the water and noises of a cleaning so when more extensive treatment is needed, it is not such a big deal to them. For those children who have a harder time than most, well there are several tools that can be employed. The best and most often used are verbal techniques like positive reinforcement, tell-show-do, and voice tone control. Often, pharmcologic methods are necessary to comfortably accomplish treatment. The most common is Nitrous Oxide or Laughing Gas. It is a fairly benign easy way to help the child. Often additional medications are needed to help kids to be comfortable and cooperate to accomplish treatment. Sometimes it is even necessary to do treatment under General Anesthesia in the Hospital. Many times, however, the hospital is not an option due to lack of insurance coverage, limited treatment needs, or parental preference. The option of in-office Conscious Sedation has been a good option to help kids and parents.

Things can be unpredictable as medications elicit different responses in different children. Different medications (usually oral medications) are used for different situatuions. The younger the child, the more unpredictable the medication's effect. A certain dosage on one child may make them quite sleepy and sedated, while the same exact dose will not seem to do anything for the next child. Studies have found an individual child's temperment has a lot to do with their response. Therefore, some kids are better served with treatment under general ansthesia. In fact, if there is so much work that several sedative appointments will be required to complete the treatment, then the option of general anesthesia is usually discussed.

One problem with sedation in pediatric dentistry is that you can only give what is considered a "safe" dosage. Those chidren who do not respond to that dosage, well, you don't just give twice the dose and hope it will take. That could lead to trouble. Whatever is used, you monitor vital signs in accordance with the AAPD guidelines. The whole process is some what of an art as much as a science.

I am going to start series of posts on Sedation in Pediatric Dentistry and related topics. As this is too big a subject to address in one post, here are some important links to related topics (coming in the next few weeks):

Pulse Oximeters in Conscious Sedation
Sedative Drugs used in Pediatric Dentistry
How Children Behave at the Dentist, What to Expect

61 comments:

ChefWeb said...

My 2 year old received 4 white crowns on her front teeth yesterday. She had a slight fever before she went in due to a cold. Since she came home she has not eaten anything and I had to struggle with her to take fluids, thank God she did. I am going to take her to her pediatrician today but I wanted to know what side affects she could be suffering from the laughing gas. I know she really needed the procedure done but I feel guilty now for putting her through it and am anxious about sending my 6 year old back (who got stainless crowns in the back) to get the other side done. I truly believe that the staff is very good with children and professional but I can't help but worry.

Dr. Dean Brandon said...

Laughing gas pretty much goes away after about 10 minutes. There would be no long term effects from that.

Good to get your child checked out. This time of year there are a lot of bugs going around. BTW, I do not sedate children who do not meet the criteria one of which is to be generally healthy (no fever, colds, etc). Hey, with kids you sometimes don't know if they are coming down with something till it's a full blown cold. I would wait on any further dental treatment till you have consulted the physician and make sure he is ok. Good Luck.

Anonymous said...

My 3 year old daughter has a cavity on two molars.
Her dentist (our first visit) wants to fill them while she is sedated and using nitrous oxide. I'm a bit concerned using two methods to "relax" my daughter. After some convincing I agreed to the nitrous. When I went to the reception to schedule an appointment for the procedure, they explained to me that I would not be allowed in the room during the procedure. I asked if I could be there while my daughter was under sedation and they said it was their policy. I left without scheduling. Is this common practice?

Dr. Dean Brandon said...

Two issues:

1. Although Nitrous is an analgesic "sedative" agent, it is not generally though of in the same category as the other sedative medications like Demerol. It's pretty benign IMOP, still consult your dentist for possible concerns there.

2. Parental presence--see my post on that. In our office, we let the parents be there, but do not encourage it. There are good reasons both ways on that one.

momof2 said...

My 3 year old sits wonderfully for the dentist. However, he gags when they try to work on his cavity. The dentist wants to use i.v. sedation. Is this appropriate for one cavity that does not even hurt?

Terrified Mother said...

please help. my daughter night nursed til she was 2. She is 3 now with severe cavities. She has one extra tooth. I took her to the dentist and the dentist wants to pull all five front teeth and put stainless steel crowns on the rest of her teeth under iv sedation using propofol. She wants to do this at her dental office. She does not believe the front teeth are savable, and will not restore them. I am worried about the sedation and I am worried about my child having no front teeth til she is 7 or 8. What are my options and in your opinion what would be the best for my daughter. Please advise.

Dr. Dean Brandon said...

I often need to remove baby teeth in the front due to extensive decay--most kids do very well after that. If it is a pediatric dentist doing the treatment, make sure and have all your questions answered--that medication sounds like general anesthesia to me.

Anonymous said...

My 2 year old son is in need of 2 fillings and 2 crowns. The dentist suggested sedation but I have read that in cases with asthma it could be a problem. My son has moderate asthma and is being treated. Can you talk about the possible risks with asthma? Without sedation the dentist said it may take as many as 4 to 5 visits to complete the work that is necessary.

Dr. Dean Brandon said...

Asthma is a serious medical condition and should be taken into consideration when administering sedative medications. Each case is different but Asthma under control does not mean a patient should not be sedated. I have sedated many patients with controlled asthma with no problems. It usually means proper precautions and dosages should be used.

I cannot say it is good or bad for you. It is always ok to ask the dentist and consult the child's physician (although physicians are not usually familiar with pediatric sedation and the dosages/etc used), but they are familiar with the particular patient's condition.

BV said...

My 5 year old went to the dentist today and had to be held down by the assistant to have his teeth cleaned. They found a cavity and want to put a silver cap on it. The nurse had me sign a form agreeing to let them place him in a papoose board to do the procedure. Of course, when I got home I started researching the papoose board and found some very disturbing information on the use of it. What is your opinion on the use of this device?

Dr. Dean Brandon said...

I'm glad you brought that up. Although not routine, the Papoose is sometimes used in conjunction with dental treatment. Some kids can be too resistant to complete any kind of treatment unless movement is kept to a minimum. You might have noticed, if kids do not want something, sometimes they are very strong and physically resist even a quick exam. Movement of the patient can be dangerous--sharp instruments, high speed burs. Control and comfort are important.

It would be nice if we could just utter some magic words to calm a child--sometimes that does work, but premedication is often needed to reduce anxiety and limit those disruptive movements. Many times even at safe dosages, the kids (especially preschoolers) are still crying/moving/ (although pretty drunk from the meds). If a child is just a little wiggly, reaching up or something, just holding hands can help. But if a child is very disruptive (and they can be VERY fussy), a papoose is a safer way to control the patient. Some patients actually calm down a little with it on as they seem to feel more secure. I have never seen any bad consequences from use of the papoose. Most kids are no worse for wear, it's the parents that tend to get, lets say, stressed out.

There are times (and/or parenteral preference) where you simply would choose not use the papoose, especially if it simply upsets the parent too much. Of course most of the time you would not then be able to complete treatment. At that point discussions would need to take place to determaning alternate methods--usually general anesthesia in the hospital which would obviously create an ideal environment to safely complete work, but is not something to be taken lightly either. Of course you could simply not do the treatment and hope things do not get worse before the child matures enough to cooperate without restraint or medication. I use the papoose sometimes, but not often--and always with parenteral permission. If you do not want your child restrained, you may need to consider alternatives, because a dentist and staff cannot be expected to render proper safe and good treatment without having the child at some level of control. I know it can be emotional. It may be that a papoose would not be used if the child is well sedated and cooperative, but some offices use it every time for sedations--for instance to prevent a heavily sedated child from falling of the bench/chair. You indicated your child was disruptive for the exam and cleaning. That would give you some indication as to his ability to cooperate for dental treatment.

Thank you for bringing up you concerns as it allows me to address at least a little bit that subject.

Dr. Dean Brandon said...

Oh, one more thing, a papoose is usually simply a cloth wrap with velcro closures, just like what you would visualize an American Indian mother using for her baby. There may or may not be a padded "board" on the back.

spiritturtle said...

My 4 year old son had his first dentist appointment last September, where they found a cavaty on each molar. He had his first cleaning, and a month later we went back to get two cavaties filled. It took three hours and he only came out with one cavaty done, and broken capillaries under his eyes from crying so hard. They never even came out to let me know he was having a hard time. We scheduled an appointment for another cavaty to be filled, and came back a month later. This time we were there for five minutes, and was given a referrel to a sedation dentist, (only later to find out, the dentist didnt even do sedation!!) Needless to say my son still has three cavaties, an appointment with a dentist 45 minutes away that I had to find myself, (for the sedation), and a new dentist. Should I take him in to be sedated, or should I let his new dentist try and fill his cavaties without the sedation? (We were pushed around a lot at his old dentist, and was wondering how much of them mistreating us contributed to him being upset during the procedures...)What are the risks of sedation? Thank you!!

Dr. Dean Brandon said...

Sounds like you may have lost confidence in your present dentist. I would suggest taking your child to a specialist in Pediatric Dentistry. There really is no such thing as a "sedation dentist" per say. Some dentists do more sedation type cases than others--all Pediatric Dentists are trained to use sedation whether they make it a large part of their practice or not.

See my other posts on behavior management, sedation, etc.

spiritturtle said...

Thank you so much for your fast response! Yes, we have lost faith in our old dentist. I felt like we were being thrown around way too much. I have an appointment for him on Thursday with a dentist who will do the sedation. Should I go through with it, or cancel it and have him reevaluated by his new pediatric dentist? Thank you. :)

Dr. Dean Brandon said...

I cannot advise specifically, but a new Pediatric dentist would do a new examination I'm sure. Go with your gut.

Anonymous said...

My son just turned 5 he is adhd and the ds scares him.he has bitten him several times. He throw up during cleanings and when taken xray he spits the films out. they used the hand held xray with a bit gaurd. an average cleaning for him is about 1.5 hours. he has a cavity on the lower teeth and they want to fill it before to long so they dont have to cap it like the one before it. the only problem is they want to sedate him again with conscious sedation which last time they wavied the fee. my insurance doesnt cover this and i dont have the money for it. is there any other way to do the filling.

Dr. Dean Brandon said...

ask your dentist, but looks like your options are limited.

Anonymous said...

We just returned from our first official dental visit for my nearly-2-year-old son. He got his teeth very, very early. I had been concerned about his top four front teeth for several months. At his regular pediatric visit four months ago, after I explained my concerns, the doctor took a look and reassured me that the teeth looked fine. But, I was still concerned and tried to schedule an appointment with a highly reputed pediatric dentist in our area. However, they wouldn't set the appointment until after his 2nd birthday, per their policy. I then tried to have him seen by a family dentist, who couldn't get a very good look due to my son's unwillingness to fully open his mouth, but that dentist said things were probably fine and it was awfully early to have problems. I was STILL concerned so I made today's appointment. It turns out he has five cavities! Four are on those front four teeth, and one is on a molar. I'm beside myself!! The dentist was extremely helpful and informative and supportive, which I appreciated, but after months of concern, to find out that this situation has been real and not in my imagination, and has been getting worse all this time... it's so upsetting. The bottom line is that the dentist is recommending sedation per an anesthesiologist, x-rays, four crowns, the molar cavity fix, and anything else shown as necessary from the x-rays. My husband and I are clear that we want to do what's right for our son's health, but we're very concerned about the anesthesia. We have the anesthesiologist's contact information and plan to ask questions such as what the exact anesthesia will be, what the risks are, how they will know that his brain isn't being harmed, what happens if he has a bad reaction to it of some kind, etc. What other questions should we be asking? What advice can you give us in general? We're so sad.

Dr. Dean Brandon said...

I see young children every day who have lots of cavities. They can form quite rapidly sometimes. I am a little surprised a pediatric dentist would not see a child until two, as I see one year olds every week or two with caries. Be that as it may, I can understand your apprehension. There are risks to any medical dental procedure. You have to get as much information from good sources as you can and make a logical decision. You also need to understand the risks of doing nothing as well (like infection, bigger problems later, etc).

As far as cavities and procedures, you can find a lot on the blog abput that is you look enough. I often reccomend general anesthesia as my post indicates as most very young children cannot cooperate like you would hope. I would be encouraged that an anesthesiologist (M.D.) is handling the anesthesia part of the treatment. Still, anything is ultimately up to you as the parent. Cavities is a disease process, do not blame yourselves. You are being good parents in my opinion by trying to get good dental treatment for your child. Good luck. I would be interested in how it goes. Post again later!

Sam Johnson said...

Great Blog!
My son is 5 1/2 years old and 2 days ago he complained of pain in his gums. Over the course of the next day his cheek swelled up considerably. The dentist explained that he had a large cavity on the back side of his back molar(baby tooth) and suggested extraction while under sedation. They also said he had 2 other very small cavities that they also wanted to fill at the same time...and since he would already be out, a tooth cleaning too.

I was ok with it, but my wife has reservations regarding putting him under full sedation. The dentist wants it because of the size of his mouth, the amount of work needed, and the sensitivity of his cavity and swelling. My wife prefers local anestetic. What do you suggest?

Thanks!

Dr. Dean Brandon said...

Sam,
Every case is different. Sedation is often indicated, but if the child is cooperative and I otherwise think he would do great, we do not use sedation. However, if I think it is needed, than I make that reccomendation because it will really be the best way. For an extraction, a dentist will use local anesthesia no matter whether the patient is sedated or not. When you say "totally sedated" that can mean general anesthesia (which is totally asleep), which is something other than consicious sedation -and I have posts on that too.

Anonymous said...

My 4.5 year old saw a pediatric dentist because of cavities in his rear molars. The dentist is recommending he go to the hospital to be put to sleep so that an extensive amount of work can be done. I'm not opposed to having the work done but the dentist is saying that he won't leave any work undone while the child is asleep. My insurance is a discount plan so the cost of the surgery is above $3000. I was asking that they take care of the larger more immediate work and leave some of the minor work for at the office in a chair with maybe gas. The destist won't even consider this, I got the this is the way they are trained and they won't vary from it. Unfortunately I feel stuck because my child is in pain and we need the work done. Is this really the case, pediatric dentist won't leave any work undone while they have the child put to sleep?

Dr. Dean Brandon said...

I often tell parents I will attempt to accomplish all needed treatment while the child is in the hospital, so we will not have to come back for more work in the office later. Often behavior and a child's tolerance of needed treatment has to be taken into account.

I often will tell parents hey, we can do one tooth at a time, but the advised method is often the easiest on the child, most efficient, and ultimatly the most economical. Each case is different. Financial considerations are always a consideration, but I do understand what the dentist is trying to do-may not be communicating it very well. It's ok to ask for options or explainations.

SM said...

My 20 month old is going to have to have his front tooth extracted (it is split in two, with one piece shorter and more forward than the other). The dentist wants to put him under general anesthesia but cannot do it for about a month due to the scheduling. Is it safe to wait that long? He has no pain, but it is a little bit red and swollen. It is a pretty bad fracture and I am concerned about infection and the possibility of it damaging his permanent tooth. Also, I'm concerned that he is too young for general anesthesia. Are there different types of IV medications that could be used to sedate? Some that are safer than others?

Dr. Dean Brandon said...

Ocassionally general is the best choice, but sometimes if it is a simple extraction, we use oral versed -you can read more here. You probably should discuss options with your dentist.

Dr. Dean Brandon said...

Very young children with treatment needs do present a challenge because there is often no obvious good solution. It often depends on what you are trying to do-simple or complex, the level of cooperation needed, and a million other things.

Anonymous said...

When a child is given oral sedation medications is the person giving the meds supposed to be licensed?? I took my child and they have an un licensed assistant that draws up the meds and gives them after simply showing the doctor. Is this legal? or safe?

Dr. Dean Brandon said...

I our office I personally draw up the medications myself, but I do not think there is a law one way or the other except that the doctor takes ultimate responsibility. I let the assistant actually administer the medication to the patient as they are way better at getting a child to take it than I am.

Each state's laws are different and the term "licensed" varies. Doctors and Dental Hygienists in our state are "licensed" however, all employees are under the direction of the doctor. If you think about it, Nurses and assistants in physician's offices draw up and administer meds all the time. Safety is always a concern no matter who does it.

Adelle said...

I have always trusted my providers to make sure these medications are implemented properly. I am always inquisitive and make sure I know what my kids are getting. If I felt uncomfortable I would postpone treatment and find a provider that I was more confident in. At some point we have to trust the professionals.

Anonymous said...

My 4 1/2 year old has 8 cavities 4 are which from a trauma she recieved when she was two. Her pediatric dentist wants to put her under concious sedation for all of them to be fixed at once. She is scheduled for late January. However when she had her trauma at two they sedated her for the CT scan with three shots of Ketamin and she was so sedated she quit breathing but RT tech was able to just move her chest and she stared breathing again. I know they won't use this drug and it will be done at a surgery center, but I am thinking about canceling it and going old fashion way but she does not take well to people messing with her. I am so scared for her to go under sedation. Should I be worried what's the risks? What is your take on the situation?

Dr. Dean Brandon said...

Consicious sedation is just that-conscious (awake). Ketamine is a general anesthetic not usually used in pediatric dentistry and then it would be only in a hospital setting. As far as consicious sedation. We use it every day here, in fact I have a case this morning. As you can read, it is often indicated and beneficial. Ask your dentist what would work best in your case. Some kids really can benefit from it and others, it is not indicated.

Anonymous said...

Dr. Brandon,

I visited a pediatric dentist in my area today and was told that my 4 year old needs 4 crowns on her back molars and that 4 different treatments would be necessary since they were located in all 4 quadrants of her mouth. While she handled the visit SURPRISINGLY well, I am not sure how well she will tolerate things when treatment actually begins. I HATE the idea of having to bring her back 4 times and wondering whether it would be good to look for a dentist who could offer conscious sedation and do the entire thing at once given the amount of work needed. Am I overreacting? If I were in the chair, that is what I personally would want but I don't think like a 4 year old. Should we try with just gas first and "see how it goes"? My gut tells me to go right to sedation. I realize this carries risks, but so does crossing the street. I want to put the odds in my favor and do what would generally be recommended.

Great source of info you provide here. Thanks in advance.

Richard

Dr. Dean Brandon said...

Most (but not all) Pediatric dentists offer some form of consicious sedation. I have treated many 4 year olds without incident and without any medications or sedation. However, if there is more than one or two visits needed, then the option of sedaton is certainly on my list of possible treeatment options. Little ones often will do well for a little work, but if there is a lot or too many visits things might change. Still, every patient is different and you should discuss treatment options with your pediatric dentist. Please read more here on the blog about the way children behave in the office and behavior management techniques. Good luck.

Anonymous said...

My son is 3 1/2 years old. In the past we were given a perscription of 1 valium he took an hour before our appointment, it didn't help and during that visit they tried using the papoose with no luck. I tried another Doctors office at which time just using gas we where able to put one crown on and fill a cavity between the two front teeth. However, a day later the filling between the two front teeth fell out. We return to try and refill the cavity but because of his behavior we where unsucessful. He recommended taking him to the hospital to be put under. After he explained the process to me..of him not being able to breath on his own and being put on a ventilator, I am terried to do this. I decided to wait until he got a little older thinking he may do better. Although we brush his teeth and use fuloride daily he now has more issues.
He needs 1 crown, 3 cavities filled and the cavity between the front two teeth either crowned or filled. The dentist is recommending In Office Sedation ..with what they call a "Cocktail" and Gas , I have not gotten a straight answer of what this "cocktail" consistive of ( i'm waiting a call from their office ) Or he can be put under at the hospital. I only want to do the safest thing! Can you please tell me if there is one safer than the other? What is your thoughts on filling the cavity between the two front teeth vs crowning them? Thank you in advance.

Dr. Dean Brandon said...

You can read more here about crowns vs. fillings. Basically, --small or medium sized cavity=filling,-- large cavity=crown.

I just treated three children this morning under general anesthesia for their dental work. Often, this is the best way to accomplish the objective of good, intricate dental work, with a cooperative patient with minimal disruption to the patient.

As you can read here, sedation is often an alternative to general anesthesia. Sometimes, however, it is not. One of the children I saw today, we had attempted in office sedation, and it was not successful. One cannot often predict what will be the ideal treatment modality. Some kids do great with no sedation, some need general anesthesia.

Anonymous said...

We took our two year old for his second cleaning and they discovered two cavities that spread across his front four teeth. They recommended them be fixed at the hospital and he be put under for the procedure. I had to pay $966 up front, and $500 of that was a fee the dentist charges to drive from the practice to the center which is not re-imbursable by my insurance. Total before insurance paid for everything, the bills amount to over $8000.00, with my out of pocket being close to $2500. It was $5500 for the hospital, $2000 for anesthesia, $1800 for the dentist. Is that normal?? I can't wrap my head around having four teeth filled and it costing more than delivering a baby.

Dr. Dean Brandon said...

Insurance companies are bizarre on what they cover and what they do not. Whatever the outcome, the patient usually ends up on the short end of the stick so to speak. Looks like the dentist's fees were the lowest of those you listed. I believe what you are referring to is general anesthesia in the hospital not in office sedation. The dentist has no control over the charges of a hospital. Each case is different, and it depends, but the dentist's fees you mentioned are not unusual for a moderate amount of dental work on a young child. The fee "just to drive" to the hosptial is likely reflective of not only travel time, but pulling two assistants and the doctor and some instruments and supplies out of the office for several hours. (We have a similar fee although not quite as much). Hospitals usually fee a base fee plus by the amount of time in the OR, but, as you can see, it's still a whole lot!

Think about if you had no insurance at all. That is one reason (among many) that in-office sedation is offered as an option for some cases. Still, we have several young children every week whose cases need to have general anesthesia. In-office sedation is just not an appropriate option for them.

See my other posts on hospital dentistry, etc.

mcorbettbm said...

My 19 mo yr old daughter was diagnosed with a gum infection when i took her to see a dentist bc i noticed her gums where swollen. They told me yes she has a gum infection and also she has two cavities. The office that day was pretty busy, so he told me to come back and hed clean her teeth and prescribe medication for her. He took her back, bc parents are not allowed, when he brought her back to me he told me he filled in her two cavities too.(while she has an infection in her mouth?), Wed, was the Dentist appointment, and She had past away in her sleep Friday morning. Toxicolligy test are in the process, but what i found out was he gave her nitrous oxide when he realesed her detal records. I was not aware she was even going to get her cavities filled that day, but giving a 19 mo old notrous oxide with severe asthma problems? Everything thats been happening has just been crazy, Can you please help me out or give me feedback on your opinion of what have shouldve happened that day?

Dr. Dean Brandon said...

Oh, my. If I read your comment correctly, this is a tragedy. I cannot say if any kind of dental treatment had anything to do with this or not.

Just a general remark: Nitrous oxide is fairly mild and has a very good safety record. The effects wear off in a few minutes after administration is stopped. In the extremely rare cases when dental treatment and sedation have been implicated in morbidity or mortality, it is because of many things going "wrong" at once like large overdosages of several medications, underlying medical conditions, inappropriate medical response or monitoring, or protocols not being followed, etc. Most every case I have read, problems have happened the day of and during drug administratin and treatment, not several days later.

If you want to contact me further, please feel free to mail me at our office: Dr. Dean Brandon Alabama Pediatric Dental Associates and Orthodontics, 4001 Balmoral Drive Huntsville, Alabama 35801. God Bless.

Krystle said...

my 9 yr.old has been treated for serve anxity under a physciatrist for the past 2 yrs. his anxties r a better but still there. Last yr, he flipped out at the dentist & they were unable to fill his second cavity. I was told to bring him to a pediatric dentist which we did today . they told us they would give consious sedation & sweet air when we made the appt. Once we showed four the appt. today they said they can only give himsweet air as he to old medicaid won't pay & if we pay they will only give the dose of a child 1/2 his size.Once home they called & said once sweetair was give &if he was unble to do the work ,they would tie him to a board COULD NOT & stop them. Is this true & any suggestions?wWe have CDPHP (medicade).Live hunter,ny Help please.Also said valium wouldn't work before sweet air from physc.

Dr. Dean Brandon said...

As I read this, it sounds like they are saying they will try with just the "air" (I presume nitrous oxide), but if that does not work the only choice is to restrain to do the work? I have no idea on the Medicaid payment or not. It does sound like he might be a candidate for conscious sedation. I do not know why they would alter the dose based on Medicaid or non-medicaid. I suspect they might have been saying that if they do use sedatives, they would use a small dose due to his age or weight. It could also be that the only medications they feel comfortable using is a milder one. It is unclear.

Valium can help someone with anxiety, but for more severe cases other meds might be needed. Firstly, I would not do anything you are not pretty much ok with and understand the possible outcomes. Problem is, there are no easy answers especially if the doctor cannot use the best method for whatever reason. Also, make sure the dentist is a specialist in pediatric dentistry. He may be, but it is not unusual for parents to request no sedation because of financial reasons. Sedation is a costly method, but usually not as costly as general anesthesia.

Yolanda said...

My daughter is 2 and has four cavities since she didn't stand still at her check up they said they have to put her to sleep when they work on her teeth she has asthma and Ive been reading articles about kids that die under sedation. What should I do? Also that dentist office has only been there a year and they would put her to sleep there. Should I let them put her to sleep there go to a University Hospital or rather them not put her to sleep and just tie her down?

Dr. Dean Brandon said...

Yolanda. Any decision is ultimately up to you. Each case is different, but usually a two your old, I'd say most of the time we are doing work under general anesthesia in the hospital. We do many sedations in the office as well. As you read here, sedation is a serious issue. When proper guidelines are used it can be a safe and effective manner to accomplish work. Still, if you have read anything here, you will have seen medications and the reaction to medications is variable. Many two year olds, well, they will still be resistant to treatment even after sedative medications. Once they are say, four years old the medicine is more predictable. It is always ok to ask for more information if you are not sure.

Mommy1 said...

Hello.
Help PLease!!!!
My 16 month old has cavities on the backs of 2 out of his 6 teeth. PLus a fracture in the front of one of the above 2. We have gone to 2 different dentists so far and they both have extremely different views on treatment. 1 wants to papoose and the other wants to put him under general. I am going to try a third, just to see what another option might be. Is it possible to do nitrous oxide on a child this young? I am lost!!! I know papossing is out for me, but general anethsia sounds a bit extreme. Is there a major risk if we wait until he is 2?
Any advice would be great. Thanks :)

Dr. Dean Brandon said...

I can't really in a specific case, but cavities do get worse with time. Having a very young child with treatment needs does present with tough choices. If you do not feel comfortable with the papoose, then I would not do that. However, many people in similar circumstances do have a few choices: You can read more on the blog here of course. There is a lot of stuff about this situation. Nitrous oxide laughing gas is very wimpy on a preschooler, especially a one or two year old.

In office conscious sedation may be an option that might be considered, however, medicines at safe dosages vary in their response the younger the child--in other words it might not sedate them enough to get the job done. I did have a two year old today where it worked great. General anesthesia is predictable and the work can be done with him asleep--often this is the best choice especially if there is a lot of work to be accomplished. I don't do too many one year olds in the hospital-I usually wait till they are two-but I have done several older one year olds. If you wait till age two, things may be worse, and the behavior issue will likely still be there, (but if you would feel more comfortable at two then discuss this option with your dentist to see how bad things might be by then (like more treatment needs). So, in summary, read more here and of course ask your dentist (who I hope is a pediatric dentist) for all the options. Good luck and God Bless. I am sure it will all be ok.

Anonymous said...

My 3yr. old went to the dentist yesterday to have 3 crowns done. I had agreed to conscious sedation. After finishing the dentist remarked how she had never had a patient do as well as my daughter. She did not cry or fall asleep. She did use the papoose board which is always done at this particular office. It was within 10-15 minutes of leaving the office that my daughter started reacting to the medication. As soon as we got home I thought she was going to take a nap and instead she started thrashing around, crying, not speaking clearly and trying to walk which she could not do on her own. It was very similar to dealing with an intoxicated adult. After speaking later that evening to my dentist she said that my daughter had a very delayed reaction to the oral medication. The medication was given around 1:10pm and her erratic behavior began around 2:45pm. The behavior lasted for about one hour before she fell asleep. After sleeping for one hour she woke, ate, and was back to her normal self. Have you ever heard of this happening. A child being very calm and responsive during the procedure then later reacting aggressively?

Dr. Dean Brandon said...

Firstly, oral medication can be a little unpredictable as absorption rates from the gut vary. I have seen kids seem a little loopy after the procedure. They can be disoriented or not understand how weird they may feel. The max effect would be during treatment (usually) that's why they seem to do so well. Then later on a different reaction. Not common but can happen. The main thing is to make sure they meet discharge criteria before leaving the office. Versed is particularly known for some kids being inconsolable after treatment. Bit that's usually very young preschoolers and even then only about 10% or less of them.

snowflake130.52 said...

My 2 year old, 30 pound daughter needs to have extensive dental work done including cavity fillings and root canals . The pediatric dentist stated that she would need to use oral sedatives which I am not comfortable with. How safe are these products especially for a child her size? Also, would it cause more harm to just wait to have the work done in another year or so?

Dr. Dean Brandon said...

Sorry I cannot comment in detail. I am at a meeting. Basically medications can be ok to use at correct doses etc. Etc. A two year old is highly unlikely to cooperate without any meds. Usually general anesthesia is needed because oral meds are very unpredictable in 2 year olds. If it's a lot of work you can inquire. If it's just one tooth a quick thing then that's different. Some baby teeth stay till 12 years old or older.

Anonymous said...

We 7 year old son is going to have two molars extracted and spacers put in. He is allergic to milk and eggs and I'm wondering if any of the possible sedation drugs or the spacers could pose a problem due to his food allergies.

Dr. Dean Brandon said...

I have not seen a problem with just food allergies and sedative drugs. It is important to coordinate with your doctor and provide a good medical history to avoid any problems. Most of the time I see antibiotic allergies like penicillin allergy.

Anonymous said...

My 3 year old son had some decay on his upper front teeth. So, we took him to have x rays done. The dentist recommended that we do the procedure in the hospital, which I agreed to. His office submitted the pre-treatment est. through insurance, at the worst case scenario with caps and everything. So my wife and I paid for everything up-front. After the procedure was done then I got a bill from the hospital, not the dentist. So, I was concerned because caps were not needed, but fillings were used. Which resulted in a lot cheaper procedure, which I thought. I contacted the dentist's office and they said that there was no balance. But after looking into it I compared the hospital call on the pre-treatment est. and the EOB from the dental insurance, and there was a difference of $261. How can this be? This seems unethical! Also, is any of the dental work covered under medical?
Thank you for your time!

Dr. Dean Brandon said...

We have over a dozen employees just to handle and figure out insurance. There are hundreds of policies. Most policies change from year to year, so I cannot really comment on insurance as I do not have enough information. I can say that, at least here, for hospital cases, the hospital's bill (anesthesia services, nursing and the anesthesiologist, supplies, etc) are totally separate from our charges.

It is also not uncommon that treatment proposed (estimated) might change somewhat in the hospital once you get in there. It is common to give an estimate that takes into account the possibility of more extensive treatment. It is better to do that than underestimate and then have to tell the parent they have crowns or additional work that they may not have anticipated.

Anonymous said...

My seven year old daughter has 4 cavities. One in each corner of her mouth. They are moderate cavities. Can the dentist fill them all at once? Or will she need tocome in at different times do you think? And filling is better if they are moderate cavities than caps, right? Also, which is more painful? Thanks, worried mom....

Dr. Dean Brandon said...

That's a lot of questions. Each case is different. I had a 5 year old this morning where we did four fillings all at once with no problem. There are other kids that definitely need sedation to do even one filling or crown.

Andy & Becca said...

My 2 year old has a darkened front tooth from a trauma. I took her to a ped dentist yesterday who said it would be best to leave it until it falls out on its own (it has root resorption). However, since the appt. the last two days she has been crying and its been causing her pain. She's quit her thumb sucking habit because of the pain. I called the office, and the assistant said the first time they can get her in is on Monday (aren't open Friday). Then without speaking to the dentist first she said they will probably extract the tooth then and there. Since my daughter is in pain now, should my 2-year-old be on antibiotics until the procedure for a possible infection? I didn't see any pus on her gums.
If you didn't have much time know a two year old and needed to extract a tooth would you use conscious sedation or gen. anesthesia?

Dr. Dean Brandon said...

That's a lot of specific questions. I cannot really diagnose here. Please consult your dentist about treatment options. As you can read on the blog, there are many things to consider. Abscessed teeth often need antibiotics before treatment, but not always. Discuss behavior management options with your pediatric dentist. I have taken out teeth on two year olds with sedation, with general anesthesia and sometimes with nothing extra other than numbing up and maybe a little laughing gas. Each case is different and certainly challenging. Good luck.

.Brittney.Vaughn. said...

My 2 year old has cavities in each of his bottom first molars (one of them being rather large) and 2 facials also... The doctor mentioned Versed and Demerol. How do you feel about demerol being used as an oral sedative in children that young? Would it be safer to just use the Versed and get the work done in multiple sessions or use the Demerol and get it done all at once?

Dr. Dean Brandon said...

There is no way for me to tell you what medication would be the best. Each child and each case is different. My experience that medications in 2 year olds are unpredictable as to their effect. Yes, we sometimes use demerol or other combinations in two year olds. Even with that, some kids are still fussy and resistant-also, many do quite well. Often general anesthesia is indicated, especially for more complex or extensive treatment.

Versed is a great medication, but not often used in 2 year olds as it tends to be a little "wimpy". Still, I have worked on 2 year olds with both medications and had good results. I have even worked on two year olds with no premedication at all other than nitrous oxide and they have been great. Other two year olds, well, there is no medicine that will calm them down enough to do adequate dental work. Like I said, kids are different and the younger they are, the more unpredictable the result of any medication.

Dr. Dean Brandon said...

Well, there are over 60 comments on this post now. I am closing this thread to comments. There is a lot of information in the post and in the comments. Medications in children is a complex issue that does not lend itself to easy answers. Consultation with your pediatric dentist, anesthesiologist and other health care professionals is indicated.