Abstract
The use of conscious sedation in paediatric dentistry is very beneficial for the management of anxious children. It is essential that it is provided according to national guidelines in a safe and effective manner.
From Volume 40, Issue 9, November 2013 | Pages 728-730
The use of conscious sedation in paediatric dentistry is very beneficial for the management of anxious children. It is essential that it is provided according to national guidelines in a safe and effective manner.
Providing dental treatment for children can often present a challenge if the child is anxious and fearful or if a potentially difficult procedure is required. The use of conscious sedation in these patients can be of great benefit.
The intention of this paper is to review the main areas of current UK guidelines for the use of conscious sedation for paediatric dental patients. The reader is directed to the individual guidelines for more detailed information.
Guidelines have been produced to ensure sedation is provided in a safe and effective manner with the appropriate facilities, equipment, staff and training available. There are three main sets of guidance pertaining to paediatric dental sedation:
The SDAC document considers a child to be anyone under the age 16 years, of normal mental and physical development, with the understanding that age of maturity is variable and due discretion should be exercised.
All the aforementioned guidance documents consider similar principles in the provision of conscious sedation in children and each subject area will be addressed with reference to the available literature.
Conscious sedation has been defined as:
‘A technique in which the use of a drug or drugs produces a state of depression of the central nervous system enabling treatment to be carried out, but during which verbal contact is maintained throughout the period of sedation. The drugs and techniques used to provide conscious sedation for dental treatment should carry a margin of safety wide enough to render loss of consciousness unlikely.’1
When undertaken in children it is important that:
‘Conscious sedation must only be undertaken by teams that have adequate training and experience in case selection, behavioural management and administration of sedation for children and only in an appropriate environment.1
With regard to the sedation drugs and techniques for paediatric sedation, it is recommended that nitrous oxide/oxygen inhalation sedation should be the first choice for children who are unable to tolerate treatment with local anaesthetic alone and where more complex or invasive procedures are planned.1-3
Intravenous sedation may be appropriate in a minority of cases, particularly where inhalation sedation has been unsuccessful and ‘should only be provided by those trained and experienced in sedation for children and in the administration of intravenous drugs’.1 The 2007 guidelines recommend that intravenous midazolam sedation may be used in children 12 years and over, provided the aforementioned criteria are met.3
With regard to oral and transmucosal sedation, the SDAC guidance recommends that these should: ‘only be administered under appropriate circumstances by a practitioner experienced in their use.’ It is important also that the practitioner is competent in intravenous cannulation.1
All members of the dental team providing conscious sedation must have received appropriate theoretical, practical and clinical training. The subject areas which should be covered are given in Table 1.
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Documented up-to-date evidence of competency should be kept by healthcare professionals delivering sedation to include:
Treatment and recovery areas must be large enough for the dental team. Appropriate sedation and resuscitation equipment must be readily available.
Ensure trained healthcare personnel carry out a pre-sedation assessment and document the results in the patient's records.
To establish suitability for sedation the following areas should be considered:4
It is advised to seek advice from a specialist (eg consultant anaesthetist) if:
When deciding on the most suitable sedation technique, the following factors should be considered:
To allow the patient and his/her parents or carer to make an informed decision about the type of sedation he/she receives, verbal and written information should be provided (Figure 1).
The information should include:
Written informed consent should then be documented.
Clinical monitoring of the patient without additional electronic devices is generally adequate.
Clinical monitoring is more rigorous, particularly for children, and it is worth noting the recommended procedures as stated in the NICE document 2010.4
For conscious sedation, excluding with nitrous oxide and oxygen alone, the vital signs that should be continuously monitored are given in Table 2. It is also advisable to monitor blood pressure as long as this does not stress the child unduly. All monitoring details must be clearly recorded in the patient's notes.
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On completion of the procedure, under conscious sedation, monitoring should continue until the patient is stable and fit to be discharged. Before the patient is discharged, the following criteria should be met:
The guidance documents relating to conscious sedation for dentistry aim to promote safe and effective care. Before choosing to carry out treatment under sedation, it is imperative that the team, including clinician, sedationist and nurses, is fully conversant with the techniques being used and the patient is being managed in the most appropriate environment. It is essential to consider each patient on an individual basis, taking into account his/her needs and suitability for the sedation techniques proposed; comprehensive documentation of all stages of the patient journey must be recorded in the clinical notes.