If you’re a parent and have concerns about sedation dentistry for your child, it’s completely understandable. After all, there have been questions raised in the past several years about the safety of sedation and anesthesia in pediatric dentistry -- including reports in the media regarding complications and even deaths in some rare cases. With that said, there are some important factors to keep in mind as a parent:
· When administered by a qualified, experienced, and highly trained oral & maxillofacial surgeon or anesthesiologist in an accredited ambulatory surgical facility, sedation dentistry can be safely administered to pediatric patients.
· If your child has anxiety about going to the dentist or has special needs, sedation dentistry is a proven, effective, and safe procedure to help ensure that your child receives the dental treatment he or she needs to provide good oral health for years to come. Without dental sedation, a child may become fearful and may likely resist going to the dentist or sit still in the chair as he or she grows older, increasing anxiety and fear about having any procedure done, even a routine cleaning, and even into adulthood. An anxious and fidgety child will make the dentist’s task very difficult, resulting in less than ideal conditions and care for everyone.
What are the sedation/anesthesia options for my child?
Depending on the procedure, including the length of time it will take, along with your child’s unique needs, there are several options for dental sedation and anesthesia. They include:
1. Local Anesthesia
The simplest option, local anesthesia, involves injecting numbing medication around the area that will be treated. The local anesthetic will block the nerves in that area which transmit pain, and the patient will feel numbness in the area. Local anesthesia is almost always administered in addition to any other anesthesia treatment to minimize the amount of anesthetic required to make patients comfortable.
2. Nitrous Oxide
In young patients who are anxious about dental procedures, the local anesthetic can be supplemented with nitrous oxide, also known as ‘laughing gas." While nitrous oxide works well to reduce anxiety in cooperative patients, it does not work as well in patients who are dental phobic, or who cannot sit still for any sort of dental procedure. Patients will also often remember most of the procedure as they are usually fully aware of their surroundings. Therefore, nitrous oxide is best used primarily to reduce anxiety as it does not have any sedative or anesthetic effect.
3. Oral Sedation
With oral sedation, children are given syrup to drink or a pill to swallow, which have a sedative effect to relax patients for the procedure. The problems with oral sedation are the following:
· The medication often takes 30 minutes or more to work, so it has to be given ahead of time and before the scheduled appointment time.
· The medication lasts a long time, anywhere from 2 hours to 6 hours, so patients may go home without fully being awaken, and therefore may be inappropriately cared for at home by parents or caretakers unfamiliar with how to care for a sedated patient.
· The dose cannot be titrated, which means that if the dose is underestimated, the patient will not be sedated appropriately for the procedure. Since the medication is given orally, it is very difficult to give a second dose orally to a partially sedated patient. Additionally, if the procedure lasts longer than expected, then the medication will wear off before the treatment is completed. On the other hand, if too much medication is administered, the patient may be over sedated during the procedure.
4. IV Sedation
With IV sedation, an oral & maxillofacial surgeon or pediatric anesthesiologist will administer carefully measured doses of anti-anxiety drugs and anesthetics intended to help put your child at ease for the treatment. Because the doses are determined on a patient-by-patient basis and administered through an IV line, this can be a safe option for children who are apprehensive about having dental surgery because the doses can be titrated as needed to achieve the level of sedation desired.
IV sedation is also beneficial because your child will have little or no recollection of the procedure after the fact, meaning that there are no bad memories to exacerbate fears that may make your child resistant to future appointments and treatments. With IV sedation, the amount of medications needed to keep your child relaxed and at ease will be monitored and adjusted continuously until your child is resting comfortably for the procedure. Short acting medications are used, so your child usually wakes up pretty quickly once the procedure is finished. And in case of any complication, most of the drugs administered can be reversed right away.
5. General Anesthesia
General anesthesia is sometimes necessary for children who are unable, either because of age or maturity level, to cooperate during dental treatment. It should be noted that there are inherent risks where general anesthesia is used, and although they represent a small percentage of patients, it is always recommended that all patients be evaluated at an initial consultation appointment to ensure the best outcome for your child. The evaluation may include a thorough medical examination and blood work.
General Anesthesia is most helpful for:
· Infants
· Children who require major treatment
· An extremely anxious child
· Children who are medically compromised or have special needs and/or who have a condition which limits cooperation or the ability to follow instructions
With General Anesthesia, your child will be given medicine to put him or her into a deep sleep. This is usually performed by an oral & maxillofacial surgeon or a pediatric anesthesiologist, who will administer the medications through an IV line, although inhaled anesthetics may also be used. A breathing tube may be inserted during the procedure to safeguard your child’s airway throughout the procedure.
Important Questions to Ask Your Child’s Dentist about Anesthesia and Sedation
Again, it’s completely understandable to have concerns regarding sedation dentistry for your child. As a parent myself, I would feel the same way if I were not so familiar with the methods, requirements, and outcomes in sedation dentistry. With that in mind, I urge parents to ask their child’s dentist a series of in-depth questions in order to feel confident in the dentist, their staff, the facility, and the sedation procedure that is being recommended.
Following is a list of questions you should consider asking your dentist, which should address any concerns you may have about your child’s proposed procedure. If your child’s dentist does not take the time to answer every question thoroughly and to your complete satisfaction, I would recommend seeking another provider.
Prior to the Procedure:
· Will the sedation be performed by an oral & maxillofacial surgeon, dental anesthesiologist, or medical anesthesiologist? The American Academy of Pediatrics (AAP) and the American Academy of Pediatric Dentistry (AAPD) both recommend that an anesthesia professional be with your child while the dentist concentrates on the procedure.[i] Oral & maxillofacial surgeons have been providing office-based anesthesia for over 90 years. The American Association of Oral & Maxillofacial Surgeons (AAOMS) supports the Anesthesia Team Model, in which oral & maxillofacial surgeons, along with trained assistants, carry out administration of the anesthetic, perform airway monitoring, and the surgical procedure. Furthermore, the AAOMS “Parameters of Care for Anesthesia and Outpatient Facilities” are reviewed and concurred with by the American Society of Anesthesiologists.[ii] Therefore, while oral & maxillofacial surgeons are unique in that they have extensive anesthesia training and routinely administer anesthesia and perform surgery safely, you should discuss all these options with your dentist and choose the treatment plan you are most comfortable with.
· Confirm that the procedure will be done in a facility accredited for ambulatory surgery.
The American Association for Accreditation of Ambulatory Surgical Facilities, Inc. (AAAASF) provides accreditation for medical and dental offices. It sets the standard of care required in an outpatient setting to provide anesthesia services safely. No office should offer anesthesia services without being accredited as an ambulatory surgical facility. It would be like a hospital operating without an accredited operating room. If the facility is not accredited by the AAAASF or another reputable accreditation agency, you may want to seek another provider or request that the procedure be performed in a hospital. For more information on the accreditation process, please visit www.aaaasf.org. (Note: in New York State, all physicians are required to operate in an accredited surgical facility. This requirement has not yet been implemented to dentists, which is why you should always insist that your dentist operates in such an accredited facility).
· Ask the dentist if he or she has hospital privileges, and ask if you can have your child’s procedure performed in a hospital. This should always be presented to you as an option.
· Who will provide the pre-operative evaluation? A thorough review of your child’s past medical history, surgical history, medications, allergies, and previous illnesses or hospitalizations should be reviewed on every patient prior to surgery.
· What is the recommended time that your child should be without food or drink prior to the procedure?
· Will any sedation medication be given to your child at home prior to coming to the office? If so, how should he or she be monitored before arriving into the procedure room?
· What training and experience does the sedation/anesthesia provider have in providing the level of sedation or anesthesia that is planned for the procedure? Does this training and experience meet all of the standards of the ADA Guidelines for the Use of Sedation and General Anesthesia by Dentists?
· Does the staff assisting in the procedure have current training in emergency resuscitation procedures, such as Basic Life Support and other advanced resuscitation courses as recommended by the ADA Guidelines? Is this training regularly renewed?
· Does the state dental board require a special sedation/anesthesia permit or license that allows for the sedation/anesthesia provider to administer this specific level of sedation or anesthesia in the dental office?
During the Procedure:
· In addition to the use of local anesthesia, what level of sedation/anesthesia will be given to your child? Is it minimal sedation (relaxed and awake), moderate sedation (sleepy but awake), deep sedation (barely awake) or general anesthesia (unconscious)?
· How will your child be monitored before, during, and after the procedure until released to go home?
· Are the appropriate emergency medications and equipment immediately available if needed – and does the office have a written emergency response plan for managing medical emergencies?
After the Procedure:
· Will the sedation/anesthesia provider give you instructions and emergency contact information if there are any concerns or complications after returning home?
What we do at Park Smiles NYC Pediatrics
As an oral & maxillofacial surgeon in a pediatric dental practice, and as Medical Director of our AAAASF-accredited ambulatory surgical facility, I take every precaution possible to maximize the safety and well-being of all our patients. And as a parent, I empathize with your concerns of having anesthesia administered to your child. Following are just some of the safety measures we have in place at Park Smiles NYC Pediatrics:
· We offer all types of anesthesia from local anesthesia, to nitrous oxide, IV sedation, and general anesthesia, with the anesthesia plan being tailored to the specific needs of each patient during an initial consultation.
· All anesthesia services are provided in our accredited AAAASF operating room by a board-certified oral and maxillofacial surgeon or by a board-certified anesthesiologist. The choice is always left to the patient/parent.
· All procedures can be performed in our AAAASF-accredited ambulatory surgical facility or at the hospital. Again, the choice is yours.
· All our staff is highly trained to assist our dental surgeons in sedation dentistry cases. All staff is also trained in basic life support skills.
· Our state-of-the-art facility is fully equipped for all types of dental procedures -- from general dentistry and pediatric dentistry to complex oral and maxillofacial surgery procedures.
It’s important not to let a fear of sedation dentistry prevent you from seeking the proper dental care for your child.
By asking the right questions, carefully choosing your provider, and ensuring that your child will be treated in an accredited ambulatory surgical facility, you can feel peace-of-mind knowing that your child is receiving safe and stress-free dental care to help him or her achieve a healthy smile for years to come!
[i] Cote CJ, Wilson SW: American Academy of Pediatrics, American Academy of Pediatric Dentistry. Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After sedation for Diagnostic and Therapeutic Procedures: Update 2016. Pediatrics 2016;138(1):e20161212
[ii] White Paper: Office-Based Anesthesia Provided by the Oral and Maxillofacial Surgeon. American Association of Oral and Maxillofacial Surgeons, 2016
Disclaimer: The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of any dental or medical association, or position of any local, state, or federal government or agency.