If COVID-19 has taught us anything, it’s that our Canadian medical system has over-relied on surgical programs operating exclusively in the hospital setting. As such, patients requiring emergency surgeries to prolong life or relieve pain have been left to succumb to their disease or live with the pain until hospitals completely re-open to the public. The need for surgical options offered by private medical establishments has never been greater.
Pediatric dentistry provides society with a tested model for how out-patient based surgery can be performed safely. Anxiety, fear and agitation are common in children requiring dental treatment and can complicate even the most harmless procedures. Pediatric dentists have been using sedation to modify unsafe behaviors in children and facilitate the completion of necessary dental interventions while at the same time, avoiding hospital Operating Room use (Al Sarheed, 2016).
The challenge for sedating children consists of determining the best route of administration and choosing a drug plan that provides adequate sedation and pain management with minimal cardio-respiratory compromise.
Methods of delivering dental sedation in pediatrics include:
IV-gold standard but invasive. Should be selected for cases that require a deeper level of sedation or General Anesthesia
Intra-muscular- Invasive and painful. Can be painful and traumatic for the child and parent
Inhalation- non-invasive but requires a compliant patient. May not provide enough sedation to modify behavior for more complicated dental procedures. Can be combined with an oral sedative for producing a deeper level of sedation
Intra Nasal (IN)- can be used for producing a mild-moderate level of sedation and facilitate the completion of frequently performed dental procedures such as the treatment of dental carries and completing dental extractions
Oral- non-invasive however, the child can spit the drug out; may be difficult to titrate
Subcutaneous- more for local anesthesia
Figure 1: a nasal atomizer
Choosing the right technique and drug or drug combination will be affected by the resources that you have at your place of business and the patient’s level of anxiety.
In situations where the child in question is mild-to-moderately anxious, an anesthetic plan using oral or IN Versed can be created and administered by the dentist.
Figure 2: Injectable Versed
IN sedation is identified by the Royal College of Dental Surgeons of Ontario (RCDSO) as a form a parenteral moderate sedation (RCDSO Standard of Practice, 2017). It doesn’t require the use of needles and is relatively painless.
The interior nose is innervated by a large vascular plexus, making it an optimal route for drug absorption (Al Sarheed, 2016). Nasal Inhalation avoids hepatic first-pass metabolism, making more drug available more rapidly than other routes (Lee-Kim et al., 2004). In Ontario, it can be used as a pre-medication or as sedation however, the dentist must meet the requirements for delivering sedation as identified by the RCDSO. Of important note is that IN sedatives do not act as analgesics and must be combined with opiates to facilitate patient comfort during painful procedures (Al-Rakaf, 2001).
Figure 3: Blood supply innervating the nose
IN Versed is a short acting, rapid-onset Benzodiazepine that can be administered in dosages ranging from .1-.5mg/kg (Al-Saheed, 2016). Some if its properties include:
Time of onset of action: 5-16 minutes and dosage dependent
Adequate sedation achieved in: 7-10 minutes
Duration of action: 40-60 minutes
Effects: anxiolytic, sedative, amnesiac
(AL Saheed, 2016)
Figure 4: Intranasal Versed Dosing
Dentists should consider the invasiveness of the surgical procedure when determining IN Versed dosing as its effects are dose dependent. Peerbhay and Elsheikhommer (2016) found that patients between 4-6 years of age having dental extractions were more calm and relaxed during the local anesthetic and extraction when the .5mg/kg dose was used instead of the .3mg/kg. A 2001 study by Al-Rakaf comparing 3 different dosages of IN Versed found that restorative dental treatment was completed in 100% of children receiving .5mg/kg compared to 79% of children receiving .3mg/kg and 96% of children receiving .4mg/kg. Complications associated with each dose were not statistically significant (Al-Rakaf, 2001).
IN Versed administration can be safely considered as either a first-approach conscious sedation option or alternative to Versed oral ingestion when the child refuses to accept the oral route in children with mild-moderate anxiety. A comparison of these 2 routes of delivery in relation to effectiveness and safety demonstrates insignificant differences (Peerbhay, 2016).
Complications and side-effects of IN or oral Versed are infrequent and include: a paradoxical reaction where the child becomes very agitated; hiccups; nausea and vomiting (Peerbhay, 2016). Parents need to be aware of these complications prior to the procedure so that they are prepared to manage their child in the post-anesthetic phase.
Careful patient selection, complexity of the procedure and medical history are important determinants for successful conscious sedation using Versed regardless of route. Patient safety is of paramount importance whenever sedation is being used to facilitate a medical procedure.
Figure 5: Mallampati Score- one way to identify a potentially difficult airway during pre-screening
A difficult airway, anaphylaxis, respiratory depression, apnea, acute cardio-vascular emergencies and aspiration are all possible complications associated with sedation dentistry (Saxen et al., 2019). Specialized courses such as Pediatric Advanced Life Saving (PALS) teaches the skills needed to manage an airway or support blood pressure until advanced emergency systems arrive (Cote and Wilson, 2019).
IN Versed at .5mg/kg is an effective and safe dose for managing mild-to-moderately anxious children during minimally invasive dental procedures.
References:
Al-Rakaf, H., Bello, L.L., Turkustani, A., Adenubi, J.D. (2001) Intranasal Midazolem in Conscious Sedation of Young Pediatric Dental Patients. International Journal of Pediatric Dentists, 11, 33-40.
Al Sarheed, M. (2016). Intranasal Sedatives in Pediatric Dentistry. Saudi Medical Journal, 37(7), 948-956.
Cote, C.J., Wilson, S. (2019). Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures. Pediatrics, 143(6):e20191000
Lee-Kim, S.J., Fadavi, S., Punwani, I., Koerber, A. (2004). Nasal vs. Oral Midazolem Sedation for Pediatric Patients. Journal of Dental Child, 71, 126-130.
Peerbhay, R., Elsheikhomer, A.M. (2016). Intranasal Midazolem Sedation in a Pediatric Emergency Dental Clinic. Anesthesia Prog, 63, 122-130.
Royal College of Dental Surgeons of Ontario Standard of Practice: Use of Sedation and General Anesthesia in Dental Practice: https://az184419.vo.msecnd.net/rcdso/pdf/standards-of-practice/RCDSO_Standard_of_Practice__Use_of_Sedation_and_General_Anesthesia.pdf
Saxen, M.A., Tom, J.W., Mason, K.P. (2019). Advancing The Safe Delivery of Office-Based Anesthesia and Sedation, Anesthesia Clinics,(37), 338-348.
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