MY CHILD IS VERY YOUNG – WILL YOU GIVE HIM/HER A SHOT?

We will do everything we possibly can to make your child relaxed and comfortable so that he or she has a positive dental experience. We do not use the term “shot” in our office. This is a very negative term that scares most children and parents. Instead we tell your child that we are going to put their tooth to sleep using “sleepy juice.”

Should your child have cavities or other treatment requiring the use of a local anesthetic for pain control we will generally proceed as follows: we will administer nitrous oxide (“laughing gas”) until your child reaches a comfortable level, after which we will place topical anesthetic in the area to be anesthetized. The topical anesthetic “numbs” the tissue in the area where we are going to administer the sleepy juice. After allowing a few minutes for the topical anesthetic to take effect, slowly and gently we will administer the sleepy juice. In most cases, using nitrous oxide, along with topical anesthetic reduces or eliminates any sensation of discomfort.

In more involved cases or in cases involving younger children we may also use oral conscious sedation or recommend general anesthesia to accomplish the recommended treatment in a comfortable, pain and stress-free manner.

DO YOU USE NITROUS OXIDE IN YOUR OFFICE?

Dental phobias are often responsible for the delay in seeking dental treatment experienced by many children and adolescents thereby causing the degree of dental decay and the resultant treatment to be more extensive and expensive. As a pediatric dental specialty office, one of our prime concerns is trying to make each dental experience as pleasant as possible for each child. For this reason we use nitrous oxide on children that we treat (of any age) undergoing operative treatment (fillings, etc.). It is our experience that the use of nitrous oxide/oxygen calms the anxious child/adolescent/teenager making the dental experience more enjoyable and less frightening. More treatment can be completed in each visit and the child is generally less traumatized by the dental experience. We believe that nitrous oxide analgesia is one of the best tools that we have to make your child’s dental experience more pleasant.

WHAT IS ORAL CONSCIOUS SEDATION (minimal or moderate sedation)?

Oral Conscious Sedation involves the administration of an agent (drug) or combination of agents designed to cause an alteration or alterations in the level of the child patient’s consciousness, cognition, motor coordination, degree of anxiety, and physiological parameters. The changes experienced by a patient will depend upon the drug used, the amount used and each patient’s individual sensitivity to the agent(s) used. When using oral conscious sedation, we are attempting to reach one of the following levels of sedation; (1) minimal sedation or (2) moderate sedation. Minimal sedation is defined by the American Academy of Pediatric Dentistry as a drug-induced depression of consciousness during which patients respond purposefully to verbal commands. Moderate sedation is defined by the American Academy of Pediatric Dentistry as a drug-induced depression of consciousness during which patients respond purposefully to verbal commands either alone or accompanied by light tactile stimulation. Although we make every effort to keep patients in either a minimal or moderate stage of sedation, patients can move from one stage of sedation to another and can enter deeper stages of sedation including deep sedation and/or general anesthesia.

Oral conscious sedation is designed to relax your child and increase your child’s cooperation thereby making the proposed dental treatment easier and more comfortable. The duration of the sedation varies from child to child but is approximately 45 minutes to 1 hour for the actual dental treatment followed by another 4-6 hours during which your child will sleep or be sleepy/drowsy. Oral conscious sedation is not always successful, in our office in approximately 10-15% of cases the oral conscious sedation does not work at all. In those cases we may be unable to complete the proposed treatment or, in some cases, any treatment, and general anesthesia may be recommended as an alternative. As with the administration of any medication, there are potential side effects to the use of oral conscious sedation (please see common risks below).

Indications for oral conscious sedation include but are not limited to:

preschool children requiring dental treatment who cannot understand or cooperate for definitive treatment; patients requiring dental care who cannot cooperate due to lack of psychological or emotional maturity; patients requiring dental care who cannot cooperate due to a cognitive, physical, or medical disability; patients who require dental care but are fearful and anxious;
patients who require extensive dental care and require or would benefit from prolonged visits; or patients who have failed treatment in other dental offices.

Oral conscious sedation is induced by a drug or combination of drugs. In our office we may use the following medications to achieve the level of sedation we are seeking: Chloral Hydrate (Noctec); Vistaril (Hydroxyzine pamoate); Atarax (Hydroxyzine hydrochloride), or Versed (Midazolam). These medications may be given alone or in combination. They may also be mixed with Ibuprophen.

A sedated child is closely monitored at all times. S/he will never be left alone! S/he may be monitored with a pulse oximeter (measures oxygen saturation and heart rate), ECG (monitors heart function), capnograph (measures air exchange), blood pressure cuff, precordial stethoscope, and/or with visual and tactile stimuli. At least one staff member will be present with the doctor at all times during the treatment phase of the oral sedation procedure. Generally, during the oral conscious sedation treatment procedure your child receives supplemental oxygen and may be gently wrapped in protective stabilization (also termed a papoose board) for his/her protection.

BENEFITS AND ALTERNATIVES TO THE USE OF ORAL CONSCIOUS SEDATION

Benefits include a reduction in anxiety/fear concerning dental care, the ability to receive dental services in an office environment, a reduction in cost when compared to receiving dental services in a hospital environment, minimal memory of the dental treatment, and the ability to accomplish more treatment in fewer visits. Alternatives to the use of oral conscious sedation are: 1) attempting the proposed treatment without the use of oral conscious sedation, or 2) putting your child to sleep (general anesthesia – either in the hospital or in an office setting) utilizing the services of a medical or dental anesthesiologist.

Each of the alternatives has benefits and risks. For example, attempting to treat your child without using oral conscious sedation may be an extremely unpleasant experience for your child (s/he may scream, cry and fight during treatment), it may create a lifetime fear of dentists and it may take more visits to complete the proposed treatment; therefore the doctor may refuse to treat your child unless oral conscious sedation is used. Putting your child to sleep exposes your child to the risks of anesthesia and will increase the cost of treatment, but will allow all treatment to be completed in one visit.

COMMON RISKS TO ORAL CONSCIOUS SEDATION

THE MOST COMMON RISKS ARE LISTED BELOW – THIS LIST IS NOT MEANT TO BE ALL INCLUSIVE AND YOUR CHILD COULD EXPERIENCE RISKS NOT LISTED:

Nausea or Vomiting – the medications may upset your child’s stomach causing him/her to become nauseated or to vomit. This is more likely when Chloral Hydrate is used because it is considered to be a gastric (stomach) irritant. Normally these problems spontaneously resolve in a short period of time and no treatment or intervention is required.

Paroxysmal reaction to the medications – In approximately 10-15% of cases, instead of being sedated or relaxed, the medication causes an increase in irritability or excitability in your child, manifested by movement, fidgeting, screaming, etc. Generally, once nitrous oxide (laughing gas) inhalation has begun this behavior will cease, but if it does not, treatment may need to be postponed.

In some cases your child could experience the following; hypotension (decreased blood pressure), hypertension (increased blood pressure), deep unarousable sleep, bradycardia (decreased heart rate), hypoventilation and/or respiratory depression (reduced breathing), airway obstruction, apnea (cessation of breathing for a time period), allergic reaction to the medications or death. These may require emergency medical attention.

WHAT IS GENERAL ANESTHESIA?
Children having extensive treatment needs, acute situational anxiety, uncooperative age-related behavior, disabilities or medical conditions may not be able to receive dental care in a traditional manner. These children may require the use of general anesthesia to receive care in a safe and caring manner. General anesthesia is a drug induced loss of consciousness. While we can treat these children at a hospital or outpatient surgical facility, treatment at these facilities may not be covered by insurance and can be cost-prohibitive. As an alternative we offer the services of a dental anesthesiologist who provides in-office IV sedation and/or general anesthesia.

Using the services of a dental anesthesiologist offers many benefits for the patient and parent. Access to care is improved, i.e. the patient can be treated in a safe and humane manner. All treatment can be completed in one sitting, and the cost for the services, while slightly higher than the use of oral conscious sedation, is significantly less than the cost of hospital or ambulatory surgery center based services. By gaining the patient’s cooperation, the quality of dental care is improved. Your child will have little to no recollection of the procedures completed.

Briefly, treatment in the office using deep sedation/general anesthesia is accomplished as follows: 1) your child should have nothing to eat for 8 hours prior to the appointment and nothing to drink for at least 6 hours prior to the appointment, 2) on the date of the treatment appointment, bring your child to the office in comfortable loose fitting clothing. Bring a change of clothing or a diaper with you (many children as they go to sleep will void), 3) the anesthesiologist will review their treatment with you (they will have also reviewed their treatment with you on at least one other occasion), 4) after answering any questions you might have, reviewing your child’s health history and determining that it is safe to put your child to sleep, an intramuscular injection will be administered, generally in the upper arm.

Your child will remember nothing after this time. Within 3-5 minutes your child will be asleep. A blood pressure cuff, pulse oximeter, EKG pads and a capnograph will be attached to monitor your child. An IV will be started, generally in their right hand, so that fluids and additional medications can be administered. After this has been done the dentistry will be completed, after which the medications will be turned off and your child will start to wake up. After approximately 15-30 minutes your child will be awake enough so that s/he may go home. S/he will still be groggy, but will have recovered to the point that leaving the office is safe. For the remainder of the day “baby” your child. Call us if you have any concerns or questions.

We find that we are recommending the use of in-office general anesthesia using the services of the dental anesthesiologist more and more frequently. We have determined that treating children while they are asleep is advantageous compared to treatment using oral conscious sedation. If you are uncomfortable with in-office general anesthesia, please discuss with us the use of hospital or ambulatory surgical based anesthesia and treatment

 

 

 

 

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