Sedation and Pain Control in Children

By Brian J. Gray, DDS, MAGD, FICOI

Sedation

While many younger patients in the dental office are cooperative and manageable without the need for sedative drugs, there are a significant number of children who cannot tolerate dental care without the use of these techniques.

For older, mildly apprehensive children, the use of oral conscious sedation may prove effective. Drugs such as chloral hydrate, Vistaril, Phenergan, and Versed are frequently used either alone or in combinations selected by the doctor. Inhalation conscious sedation, using N₂0-0₂, also is highly effective in the mildly apprehensive older child (older than six years). In some instances, the use of a physical restraint (known as a Papoose Board or PediWrap) may be necessary to minimize excessive movement (which could be dangerous) during treatment.

Unfortunately, many younger children are not mature enough to understand the need for their cooperation during dental treatment. In this situation, the techniques described above have little chance for success. Deep sedation or general anesthesia may be required for dental treatment to be successfully provided.

When this is necessary, the dentist will employ a highly trained and certified dentist anesthesiologist, medical anesthesiologist, or, in some cases, nurse anesthetist, whose sole responsibility is to ensure the safety of the child while the dentistry is being done.

Dentists trained to administer general anesthesia have received a minimum of two years of specialized advanced training and have been certified by their state Board of Dental Examiners. Monitoring devices, some of which evaluate breathing, blood pressure, and heart rate, will be employed to help ensure the safety of the procedure.

All aspects of the child's medical history, including any drugs he/she may be taking, should be disclosed to the dentist.

It is suggested that the parent ask the following questions of their doctor prior to signing an informed consent granting permission for the administration of conscious sedation, deep sedation, or general anesthesia to a child:

1. Will the child require sedation or general anesthesia for his/her dental treatment?
2. Who will monitor the child while the dentist works on his/her teeth?
3. What kind of monitoring equipment do you use?
4. Are you and your assistants trained in resuscitation?
5. Will you continue to monitor the child after the procedure, until the drug has completely worn off?

Pain Control

The administration of local anesthetics (commonly known as Novocain) is needed whenever potentially painful dental procedures are performed (even during conscious or deep sedation and general anesthesia). The administration of local anesthetics to children is extremely safe and represents the ideal means of eliminating any pain associated with dental treatment.

Local anesthetics can be administered quite comfortably. Dentists and dental hygienists take pride in their ability to administer local anesthesia painlessly.

The following are some of the procedures the doctor might use to make this procedure more comfortable for the child:

1. Place them in a reclined position during the injection.
2. Place a topical anesthetic (a gel or spray) on their gums where the injection is to be given. This should remain in contact with their tissues for at least one minute.
3. Use of a distraction technique, such as pulling or shaking the lip as the needle is slowly inserted.
4. Injecting the local anesthetic drug slowly. This is critical to a painless injection.
5. Permitting the local anesthetic drug time to work. Most local anesthetics will provide pain control within approximately five minutes after their injection.

The duration of the numbness varies from drug to drug -- some providing a short duration (two to three hours), with others providing pain control for up to twelve hours. The doctor will select a drug for the child that is appropriate for the planned dental procedure.

Since a child's tongue and/or lip may remain numb for several hours after the completion of their dental treatment, the parent should carefully watch the child to prevent them from accidentally biting and injuring their lip or tongue during this period of time.

Properly administered, local anesthetics provide safe and effective pain control in almost 100% of younger patients. If a child is unable to tolerate the injection of the local anesthetic in their mouth, it may be necessary to use one of the techniques of conscious sedation, deep sedation, or general anesthesia. Local anesthetics can safely be administered to patients receiving sedation or general anesthesia.