A Pulse Oximeter is the primary monitoring system used with Conscious Sedation in Pediatric Dentistry. Used in combination with other monitoring methods, it measures the pulse rate and oxygen saturation of the blood. It is non-invasive. In fact it is just a little sensor that shines a red light accross the finger or earlobe to measure the saturation of the hemoglobin molecule. It can provide an early warning of respiratory depression and is especially useful in children. This machine also measures blood pressure. Although, in children you are likely to see a problem with oxygen saturation before BP.
Monday, January 08, 2007
The Pulse Oximeter in Pediatric Dental Sedations
A Pulse Oximeter is the primary monitoring system used with Conscious Sedation in Pediatric Dentistry. Used in combination with other monitoring methods, it measures the pulse rate and oxygen saturation of the blood. It is non-invasive. In fact it is just a little sensor that shines a red light accross the finger or earlobe to measure the saturation of the hemoglobin molecule. It can provide an early warning of respiratory depression and is especially useful in children. This machine also measures blood pressure. Although, in children you are likely to see a problem with oxygen saturation before BP.
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I was monitoring a sedation last week and we used a lighter oral medication on a 4y8m old. She cried through the whole thing, but was fairly cooperative. I realized the pulse ox most useful when the patients are asleep. When she was crying, the alarms kept going off and it became more annoying than helpful.
Oral sedation is such an art, I've found from our faculty. What is your method is choosing which med and what has worked best in your experience?
Keep up the good posts, hopefully we can start a good community of pediatric dentistry knowledge circulating on the web.
There is "motion artifact" that throws the sensor off when the child is moving. If the child is fussy, crying, or other wise moving around you pretty much know his saturation is ok and the pulse oximeter is not of much use. I really pay attention though when the child is sleepy. That's why you cannot just rely one one monitoring modality. By the way even if you give a large amount of medication you still can have a wiggly fussy patient (which is frustrating I know). Yes, as much an art as science.
Oh yes, which medication is the "best"? There is no magic bullet here. Every situation is different. I try and gauge the behavior at the recall appointment (anxious or defiant, gag reflex, did we get x-rays or not). Then I look at the procedure scheduled, the age of the patient, weight, past dental sedations and what worked and what didn't, and other things. Younger children needing more extensive work, well I tend to lean more towards a Chloral Hydrate/Demerol/Vistaril combination. Older kids perhaps Demerol/Vistaril combination. Really short procedures on anxious kids then Versed is good. Again it all depends. All this of course if "conscious sedation" is really indicated (which, of course with most children it is thankfully not).
What are the normal heart rate values for a child say 4 to 14 while undergoing dental treatment. Lets say nitrous is being used. When should we be concerned with hypoxia or excessive heart rate (what values)
Thanks
Kids have faster heart rates than adults. The age range you give is awfully large. For instance a 4 year old would likely be 90-100.....You could look online to get a specific answer to that.
In kids you are really more concerned with a slower heart rate (bradycardia).
The pulse oximeters are necessary equipments for the dentists. These are available in most of the dental care homes. The use of these smart machines are increasing everyday.
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Our 2 year old son has to have 4 teeth worked on, one will probably require filling and at least 2 capping. We are concerned about the anesthesia procedure because he is so young. We have seen a pediatric dentist who does in office treatment and seems to have high ratings, but how can you verify a dentists has the proper qualifications to reliably use anesthesia on your child? The idea of general anesthesia terrifies me but I understand he need so much work done (and we want to knock it out in one sitting which the dentist thinks is fine) but I just want to know how to vet this dentist (not our usual dentist, was a referal) credentials as thoroughly as possible. Are there specific details I should ask about (beside being an MD instead of a CRNA) such as what anesthesia training they have had or what monitoring systems they use or what their contingency capabilities are in the case of emergency?
All Pediatric dentists (specialists) have education and training in the use of conscious sedation, and also in the treatment of children under general anesthesia, usually in a hospital setting. You could ask if the pediatric dentist is a member of the american academy of pediatric dentistry (the aapd) (www.aapd.org) Membership is not required, but gives an indication as the academy establishes guidelines for in office sedation and the necessary and expected monitoring equipment, guidelines, training etc. You can ask if he follows these guidelines. It's always ok to ask specifically about monitoring of patients for in office sedation, etc. Some pediatric dentists actually do general anesthesia or deep sedation in their office with the use of an anesthesiologist. In our office, we choose to do general anesthesia cases in the hospital. Different states have different regulations as to licensure etc.
Be aware that unless a two year old is actually asleep (general anesthesia) the reaction to medications is somewhat unpredictable. In other words he might be fussy or uncooperative even with the medications or he may be very sleepy. Unfortunately it is a difficult situation no matter what is done, or not done. I address all this more in other posts on the blog.
Read more here on the blog about sedation and general anesthesia (over there on the sidebar on the right side is a link)
My Son is 7 years old, his dentist wants to do sedation on him combination of Demerol, Valium, and Vistadril along with nitrous. Is it safe? I think it's too much
Really nice and helpful information.as Most of us have a thermometer, blood pressure cuff, or glucometer at home to track specific health concerns. We are just learning how helpful pulse oximeters are at home. Technology can be slow and initially expensive, so the use of pulse oximeters at home is just getting started. But if we have a need for a pulse oximeter, they are now easy to obtain and reasonably priced. If you are buying one on your own, you need to look at the specifications and what it will measure. If you have a heart condition and you know your oxygen saturation is usually 85%, you don’t want to get a pulse oximeter that only measures 90 to 100% accurately. A good home pulse oximeter should measure 70% and above with good accuracy.
Can I give my 8 year old .25mg of Xanax before her dental apppointment?
I only advise giving sedative medications in close consultation with your dentist. Please contact your dentist and physician before giving medications.
my 2 year old needs 4 crowns and 2 cavities filled, the dentist also mentioned possibly having to do two baby root canals. Mentioned she could get it done in about 30 minutes or so. The dentist would like to use the papoose board, a device to keep his mouth open, and oral sedation. I am ok with the papoose and the thing to keep his mouth open but wonder why he still needs oral sedation? His mouth will stay open and he won't be able to move so why sedate him as well? Also, is oral sedation safe for a two year old (he will be two later this month, his appointment is in a few days). He also has a slight cold.
Thanks!
Well, too big a question for a comment here. Please read my posts on sedation and behavior management (over there in the sidebar). Each case is different.
Hi Dr. Brandon, I read your post about conscious sedation, and my 6yrld daughter will be trying for the second time a conscious sedation because the first time did not work out, and we really can not afford general anesthesia. would giving her some Benadryl prior to appointment hinder the morphine that is used for the conscious sedation?
I would only give medications that your pediatric dentist has approved, and is aware of. I can't give specific advice on dosages, medications, etc, because there are simply too many variables. I will say in general, antihistamines like Benedryl can be of help, but are generally limited in effect, and are usually given in combination with stronger medications. They can also potentiate the effects, (adverse effects as well) of any other medications. So, tell them if you did give anything. In summary, consult your Pediatric Dentist before giving anything.
As a physician, though not an anesthesiologist, I'm out of my element trying to assess what our pediatric dentist has recommended -- our 4yo child has 4 cavities, and our dentist has recommended addressing them in 3 visits, each with premedication with hydroxyzine at 1mg/lb (yes, I said per pound -- I had the dentist repeat that several times) plus nitrous during the procedure. I was made to feel that I'd be causing my child undue distress if I refused premedication -- but isn't that dose rather high, especially considering the recent (2015) EU publication of studies indicating an increased risk of QTc prolongation and Torsades de Pointes? The highest dose I've seen recommended on paper is 2mg/kg *divided* in 3-4 equal doses over an entire day -- and our dentist is recommending 2.2mg/kg all at once. Am I right to be concerned? Or is this a standard dosage?
For reference, our child had a single crown a year ago at age 3, with local and nitrous, and did just fine. My colleagues have chimed in that most of their kids haven't even required nitrous, and did fine with just local. Thanks in advance for any info you can provide.
Pediatric Sedation is a complicated issue. There are very few proper studies of dosages for sedation on children due to the fact you can't do certain kinds of research on children. Most of the time, things we know are built up over time through experience and the limited research we can do.
As children do not respond exactly like adults to medications, it becomes less predictable. In addition, oral medications act differently as far as absorption and effect than IV or IM. For instance, first pass metabolism through the liver can reduce the effect of orally administered medications. Delayed onset or differences in metabolism from one age to another--and other pharmacological issues. Medications are given to get a short sedative response, not long term, all day management of some condition. Then there are the behavioral differences between children of different ages. For instance, the same dosage for a six year old will usually have a different response than that same dosage in a 2 year old; and there is the bell curve of responses in all things that lead to more differences.
Hydroxyzine is a somewhat should I say, less potent medication for behavior control. It is a serious drug, but relatively safe (an antihistamine) and we actually use it in combination with other medications, but by itself, well, it can work well, but I would usually only see a mild response (as far as behavior management)--which is perhaps what you want. All this is in the discretion of the pediatric dentist, and what he or she is trying to accomplish. A slightly anxious child may not need anything, or may just benefit from a lower dosage of a given medication. Another child may require much more of a pharmacological intervention, or even general anesthesia. Either way, proper monitoring health history, etc. is recommended. I strive for, if the child is premeditated, getting as much treatment accomplished, so repeated sedation visits are avoided. Most of the time, if I can get one tooth finished, I can get three or four. Of course, the child often has a (sometimes very loud) say as to what we get do--or not.
Sorry, can't be too specific. As I always, say, it's up to you in conjunction with your child's dentist. There is a lot on this kind of thing on the blog if you look around a bit.
Get a second opinion. That seems like a lot of work in very little time.
Your article is very helpful for me, I will follow your instruction. Thank you.
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