How conscious sedation plays a vital role in managing uncooperative pediatric patients in a dental setup.

1. CONSCIOUS SEDATION IN
PEDIATRIC DENTISTRY

2. • Introduction
• Definition
• Objectives of conscious sedation
• Goals of conscious sedation
• Indications / Contradictions
• Patient selection
• Sedation techniques
• Nitrous oxide/ Oxygen Sedation
• Drugs used for CS
• CS vs GA
• Conclusion

3. INTRODUCTION
• Conscious sedation is a technique in which the use of a drug or drugs
produces a state of depression of the central nervous system (CNS)
enabling treatment to be carried out, but during which verbal contact
with the patient 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.

4. Definition
• According to a definition by the American Dental Society of
Anesthesiology, a patient is said to be conscious if he is capable of
rational response to command and has all protective reflexes intact,
including the ability to clear and maintain his airway in a patent state.

5. A minimally depressed level of consciousness, that
retains the patient’s ability to maintain an airway
independently & respond appropriately to physical
stimulation & verbal commands.
(AMERICAN DENTAL ASSOCIATION,1993)

6. LEVELS OF SEDATION
• Sedation/analgesia is defined by a continuum of “levels”
ranging from minimally impaired consciousness to
unconsciousness.
• The following terminology refers to the different levels
of sedation intended by the practitioner
Minimal
sedation
Moderate
sedation
Deep
sedation
General
anesthesia

7. Minimal
Sedation
(Anxiolysis)
Moderate
Sedation/
Analgesia
(Conscious
Sedation)
Deep
Sedation/
Analgesia
General
Anesthesia
Responsiveness Normal
response to
verbal
stimulation
Purposeful
response to
verbal or
tactile
stimulation
Purposeful
response
after repeated
or painful
stimulation
Unarousable even
with painful
stimulus.
Airway Unaffected No
intervention
required
Intervention
may be
required
Intervention often
required
Spontaneous
ventilation
Unaffected Adequate May be
inadequate
Frequently
inadequate
Cardiovascular
function
Unaffected Usually
maintained
Usually
maintained
May be impaired

8. Objective
 It should alter the patient's mood, thus making him psychologically
receptive to dental treatment.
 It must allow the maintenance of consciousness throughout the
procedure.
 It must result in patient cooperation.
 It should raise the pain threshold that is usually beneficial particularly
when long appointments are contemplated

9.  It must allow protective reflexes to remain intact.
 It should produce only small variation in vital signs.
 It should not require continual monitoring of the patient as needed
when carrying out general anesthesia.
 It may produce a variable degree of amnesia.

10. Goals of Conscious Sedation
 Promoting patient welfare and safety.
 Minimize physical discomfort and pain.
 To control anxiety, minimize psychological trauma, and maximize the
potential for amnesia.
 To control behavior or movement so that the procedure can be
completed safely.
 Returning the child to a physiological state in which safe discharge is
possible.

11. INDICATIONS
According to the Royal college of surgeons and Royal college of
Anaesthetists are indicated under following terms:
• Dental phobia and anxiety.
• Medical conditions aggravated by stress such as angina, asthma and
epilepsy
• Children more than 1 year of age.
• Mentally challenged individuals.
• Ineffective local anesthesia due to any reason.
• Traumatic and long dental procedures.
• For Patients with severe Gag Reflex

12. Class I –
A normal healthy Patient
Class II –
A patient with mild
systemic disease
Class III –
A patient with severe
systemic disease
Class IV –
A patient with severe
systemic disease that is a
constant threat to life
American Society of
Anesthesiologists
[ASA-Physical Health Status]

13. CONTRAINDICATIONS
• Only classes I & II are considered for sedation in dental care settings.
Patients in ASA Class III and IV should be referred to hospital care.
• In Pediatric patients it is contraindicated if,
 The child suffers from CHD associated with CHF or cyanosis
 Neurological Impairment with Poor Pharyngeal Coordination
 Severe Obesity
 Airway Abnormalities inclusive of URTI
 Obstructive Sleep Apnea
 Raised Intracranial Pressure

14. PATIENT SELECTION AND PREPARATION
Candidates
Responsible Person
Facilities
Monitoring and rescue equipment
Documentation before Sedation
Dietary Precautions
Use of Immobilization Devices
Documentation at the Time of Sedation
Documentation After Treatment
Discharge criteria

15. Candidates
• Patients considered for minimal sedation must be suitably
evaluated prior to the start of any sedative procedure.
• In healthy or medically stable individuals (ASA I, II) this may
consist of a review of their current medical history and
medication use.
• However, patients with significant medical considerations (ASA
III, IV) may require consultation with their primary care
physician or consulting medical specialist.

16. Responsible Person
• The pediatric patient shall be accompanied to and from the
treatment facility by a parent, legal guardian, or other
responsible person.

17. Facilities
• The practitioner who uses sedation must have immediately
available facilities, personnel, and equipment to manage
emergency and rescue situations.
• The most common serious complications of sedation involve
compromise of the airway or depressed respirations resulting in
airway obstruction, hypoventilation, laryngospasm, hypoxemia,
and apnea.

18. • Other rare complications also may include seizures,
vomiting, and allergic reactions.
• Facilities providing pediatric sedation should monitor
for, and be prepared to treat, such complications.

19. Monitoring and Rescue equipment:
• Monitoring equipment are
 electrocardiography (ECG),
 size appropriate pulse oximeters,
 end tidal carbon dioxide equipment,
 size appropriate noninvasive blood pressure cuffs,
 precordial stethoscope and defibrillator (size appropriate
defibrillator paddles),
• An emergency cart or kit should be available with size
appropriate drugs and equipment to resuscitate a non breathing
and unconscious child.

20. Documentation before Sedation
Documentation shall include:
• Informed consent: The patient record shall document that
appropriate informed consent was obtained according to local,
state, and institutional requirements.
• Instructions and information provided to the responsible
person.
• The practitioner shall provide verbal and/or written
instructions to the responsible person.

21. • Information shall include objectives of the sedation and anticipated
changes in behavior during and after sedation.
• Special instructions shall be given to the adult responsible for infants
and toddlers who will be transported home in a car safety seat
regarding the need to carefully observe the child’s head position so as
to avoid airway obstruction.
• A 24-hour telephone number for the practitioner or his or her
associates shall be provided to all patients and their families.

23. Dietary Precautions
• Agents used for sedation have the potential to impair
protective airway reflexes, particularly during deep sedation.
• Although a rare occurrence, pulmonary aspiration may occur
if the child regurgitates and cannot protect his or her airway.
• Therefore, the practitioner should evaluate preceding food
and fluid intake before administering sedation.

24. • Preoperative dietary restrictions must be considered based
on the sedative technique prescribed.
Ingested Material Minimum
Fasting
Period, h
Clear liquids: water, fruit juices without pulp, carbonated beverages,
clear tea, black coffee
2
Human milk 4
Infant formula 6
Nonhuman milk: because nonhuman milk is similar to solids in gastric
emptying time, the amount ingested must be considered when
determining an appropriate fasting period
6
Light meal: a light meal typically consists of toast and clear liquids.
Meals that include fried or fatty foods or meat may prolong gastric
emptying time. Both the amount and type of foods ingested must be
considered when determining an appropriate fasting period.
6

25. • Some emergency patients requiring deep sedation (eg, a
trauma patient who just ate a full meal or a child with a
bowel obstruction) may need to be intubated to protect their
airway before they can be sedated.

26. Documentation at the Time of Sedation
• Before sedation, a health evaluation shall be performed by an
appropriately licensed practitioner and reviewed by the
sedation team at the time of treatment for possible interval
changes.
• The health evaluation should include age and weight (in kg)
and heath history including
 food and medication allergies
 medication/drug history
 relevant diseases, physical abnormalities (including genetic
syndromes), neurologic impairment.

27.  history of prematurity (may be associated with subglottic
stenosis or propensity to apnea after sedation);
 history of any seizure disorder;
 summary of previous relevant hospitalizations;
 history of sedation or general anesthesia and any
complications or unexpected responses.

28. Handbook of nitrous oxide sedation and oxygen sedation.4th
edition. Morris S. Clark and Ann L. Brunick.

29. Documentation During Treatment
• The patient’s chart shall contain a time-based record that includes the
name, route, site, time, dosage/ kilogram, and patient effect of
administered drugs.
• During administration, the inspired concentrations of oxygen and
inhalation sedation agents and the duration of their administration
shall be documented
• the patient’s level of consciousness and responsiveness, heart rate,
blood pressure, respiratory rate, expired carbon dioxide values, and
oxygen saturation were monitored.

30. Documentation After Treatment
• The time and condition of the child at discharge from the
treatment area or facility shall be documented,
• Patients receiving supplemental oxygen before the procedure
should have a similar oxygen need after the procedure
• A simple evaluation tool may be the ability of the infant or
child to remain awake for at least 20 minutes when placed in a
quiet environment.

31. Discharge Criteria
• Cardiovascular function and airway patency are satisfactory and
stable
• The patient is easily arousable
• The patient can talk (if age appropriate)
• The patient can sit up unaided (if age appropriate)
• Pre-sedation level of responsiveness achieved
• The state of hydration is adequate

32. PREPARATIONFOR SEDATIONPROCEDURES
• Sedation is used as a systematic approach so as to not overlook
having an important drug, piece of equipment, or monitor that
should be immediately available at the time of a developing
emergency.
• To avoid this problem, it is helpful to use an acronym that allows
the same setup and checklist for every procedure.
• A commonly used acronym useful in planning and preparation for
a procedure is SOAPME:

33. S (suction) = Size-appropriate suction catheters and a functioning suction
apparatus.
O = An adequate oxygen supply and functioning flow meters/other devices to
allow its delivery.
A = Airway: Size-appropriate airway equipment.eg-Laryngeal tubes, face
mask.
P = Pharmacy: All the basic drugs needed to support life during an
emergency, including antagonists.
M = Monitors: Functioning pulse oximeter and other monitors as appropriate
for the procedure.
E = Special equipment or drugs for a particular case.
American Academy of Pediatrics and the
American Academy of Pediatric Dentistry:

34. SEDATION TECHNIQUES
• There are a variety of methods for producing sedation or
alteration of mood in the pediatric patient.
 Inhalation sedation
 Oral sedation
 Intramuscular sedation
 Intravenous sedation
 Submucosal sedation

35. Inhalation Sedation
• This is the highly effective route of administration, allowing
nonirritating gases and volatile drugs to be inhaled and absorbed
directly through the pulmonary epithelium and mucous
membranes of the respiratory tract into the circulation.
• The inhalational route is the most reliable in terms of onset and
recovery.
• Efficacy is reduced when children
object to the nasal hood or have
difficulty breathing through the
nose.

36. Oral Sedation
or Enteral route
• It is the most universally accepted and easiest route of drug
administration.
• Achieved by drugs that are swallowed and absorbed through the
digestive or enteric system.
• This route is mostly recommended for premedication and
combination therapy.

37. ADVANTAGES
• Almost universal acceptability
• Ease of administration
• Low cost
• Decreased incidence of adverse reactions
• Decreased severity of adverse reactions
• No needles, syringes, or equipment

38. DISADVANTAGES
• Reliance on patient compliance
• Prolonged latent period
• Inability to titrate
• Inability to readily lighten or deepen the level of
sedation
• Prolonged duration of action

39. Intramuscular Sedation
Intramuscular administration relies upon the high vascularity of
muscle tissue to achieve a moderately rapid onset of action usually
within 5 to 10minutes.
For pediatric dental sedation, injections are typically performed in
the vastus lateralis or deltoid muscle.

40. • Indication-
• sedation of patient who refuses to take medication orally or
for some reason cannot do so.
• The pre-cooperative pediatric patient ,handicapped adult or
child patient in whom other routes have proven ineffective
• Use as premedication before the use of IV sedation or general
anesthesia
• The administration of emergency drugs to any patient in
whom the IV route is unavailable

41. Advantages
• Rapid onset of action (15 min)
• Maximal clinical effect (30 min)
• More reliable absorption (than oral, rectal)
• Patient cooperation not as essential

42. Disadvantages
• A prolonged time is still required to reach peak effect,
although it is shorter than with the oral route.
• Variability and unpredictability are seen in onset and effect.
• Total lack of reversibility.
• The opportunity for idiosyncratic reaction is also greater.

43. Submucosal Sedation
• This involves deposition of the drug beneath the oral mucosa.
• Best method is intranasal.
• The oral site usually chosen is the buccal vestibule.
• local anesthetic and sedative should not be given in same area.
• The drugs most commonly -narcotics meperidine and fentanyl.

44. Intravenous Sedation
• Intravenous conscious sedation in dentistry was introduced in
1945 by Niels B. Jorgensen.
• Advantages-
• Rapid onset of action
• Titration is possible
• Highly effective
• Recovery shorter than other techniques (IM, IN, oral)
• Patent vein is safety factor

45. – Nausea and vomiting are uncommon
– Control of salivary secretions possible
– Gag reflex diminished
– Motor disturbances (epilepsy, cerebral palsy) diminished
– Ability to perform IV is benefit in serious emergency
situations

46. NITROUS OXIDE / OXYGEN SEDATION
• Nitrous oxide is a gas and used as the inhalational anesthetic agent.
• It has anxiolytic and sedative properties with varying degree of
analgesia and muscle relaxation.
• Recent studies suggest both gamma-aminobutyric acid type A (GABA
A) and N-methyl-D-aspartate (NMDA) receptors are affected.
• Nitrous oxide is sweet smelling, colorless, non-inflammable, inert gas
and is compressed in cylinders at 750 psi as a liquid that vaporizes on
release.

47. • It has a blood gas coefficient of 0.47 and has rapid onset and
recovery time due to low solubility in blood.
• Because of being nonirritant to the respiratory tract, low tissue
solubility, and minimum alveolar concentration (mac), it has a
rapid onset, fast recovery and has a poor anesthetic effect.

48. • It is very safe because the child remains awake, responsive,
and breaths on his/her own.
• Common cold, tonsillitis, nasal blockage, patients with
porphyria, and psychotic patients are few contraindications for
N2O use.

49. DESIRABLE CHARACTERSTICS OF
N2O/O2 SEDATION:
• Analgesic Properties (Pain Control)
• Amnestic properties
• Anxiolytic properties (sedative effects)
• Onset of Action
• Recovery
• Elimination
• Acceptance

50. Indications
• Should be offered to children with mild-to-moderate anxiety to
enable them to accept dental treatment better and to facilitate
coping across sequential visits.
Contraindications
 Poor attenders and very young children
 Children having common cold, tonsillitis, adenitis, nasal
blockage, sleep apnea, deviated nasal septum
 Precooperative children.

51. ARMAMENTARIUM
• The nitrous oxide tanks are always marked blue for identification,
and the oxygen tanks are green / white.
• Nitrous Oxide-Oxygen Machine
• Pin index safety system
• Flowmeter
• Nasal hood
• Reservoir bag
• Conduction tubing
• Scavenging system

52. a
b
c
d
e

54. TECHNIQUE

55. After a thorough inspection of the equipment, Mask should be
carefully placed over the nose, delivery tubes are tightened
The bag is filled with 100% oxygen and delivered for 2 or 3 minutes
at an appropriate flow rate.
Once the proper flow rate is achieved, the nitrous oxide can be
introduced by slowly increasing the concentration at increments of
10% in every 30 to 60seconds.
The operator should encourage the patient to breathe through the
nose with the mouth closed

56. Best described as a floating, giddy feeling with tingling of the
digits. The eyes will take on a distant gaze with sagging eyelids
At this state- the local anesthetic may be given.
Once this is completed, the concentration can be reduced to 30%
nitrous oxide and 70% oxygen or lower
The dentist should communicate with the patient throughout the
procedure, paying particular attention to the maintenance of an open,
relaxed airway.

57. An emesis basin - vomiting - head should be rotated to the side
Once the sedation is reversed, the patient should be allowed to
breathe 100% oxygen for 3 to 5 minutes.
Oxygenation will purge the patient and the nitrous oxide system of
residual gas.

58. The patient should be allowed to remain in the sitting position for a
brief period to ensure against dizziness on standing.
The patient is now ready for discharge.
Even though psychomotor effects return to normal within 5 to 15
minutes, it is not advisable to allow teenage patients to drive
themselves home from the appointment.

60. ADVANTAGES
• It is a viable and cost effective alternative to general anesthesia.
• Nitrous oxide sedation has minimal effect on cardiovascular and
respiratory function and the laryngeal reflex.
• Using nitrous oxide inhalation sedation in conjunction with other
sedatives may rapidly produce a state of deep sedation or general
anesthesia

61. DISADVANTAGES
• Acute adverse effects associated with this type of sedation are
nausea.
• Chronic effects may be impotence, liver toxicity and recreational
abuse.
• Exposure to nitrous oxide can result in depression of vitamin B12
activity resulting in impaired synthesis of RNA

62. Precaution
• Diffusion hypoxia may occur as the sedation is reversed at the
termination of the procedure. The nitrous oxide escapes into the
alveoli with such rapidity that the oxygen present becomes diluted;
thus the O2- CO2 exchange is disrupted and a period of hypoxia is
created.
• However, this phenomenon is reported not to occur in healthy
pediatric patients. Nevertheless, to minimize this effect, the patient
should be oxygenated for 3 to 5 minutes after a sedation procedure, if
for no other reason than to allow for proper nasal hood evacuation of
the exhaled gas.

63. MYTHS ABOUT
Nitrous oxide-oxygen
sedation

64. Different types of sedation units that are available
commercially

65. Images- a) Accutron sedation unit
b)Parker nitrous oxide sedation
unit
c)Baldus dental nitrous oxide
sedation
d) Master flux plus system
a
b
c
d

66. Drugs and agents used for sedation in children
Inhalational
drugs
Nitrous oxide
& oxygen
conventional
contemporary
1)Lytic cocktails
2)Barbiturates eg. Phenobarbitone
3) Chloral hydrate
4)Antihistaminic eg. Promethazine Hydroxyzine
5)Benzodiazepine eg. Diazepam
1) Newer Benzodiazepine eg. Midazolam, triazolam
2)Newer antihistaminics Eg. loratidine
Systemic agents

67. Lytic Cocktails
• lytic cocktail, which combines a
• Neuroleptic (chlorpromazine),
• Opioid (meperidine), and
• Antihistamine (promethazine)
• A mixture of drugs injected intravenously to produce sedation,
analgesia, amnesia, hypotension, hypothermia, and blockade of
the functions of the sympathetic and parasympathetic nervous
systems during surgical anesthesia.

68. 25 mg/mL of meperidine,
6.5 mg/mL of promethazine, and
6.5mg/mL of chlorpromazine, with a recommended
dose of 0.1 ml/kg of body weight.
• 2:1:1 mixture, with what amounts to a l-ml/kg dosage

69. BARBITURATES
• Barbiturates are sedative-hypnotics, a type of central nervous
system (CNS) depressant used to treat insomnia, seizures, and
headaches.
• Barbiturates may also be used in a hospital setting for pre-
operative sedation.
• All barbiturates affect gamma-aminobutyric acid (GABA), a
neurotransmitter (chemical) that nerves use to communicate with
one another.

70. Pentobarbital (Nembutal)
• Short-acting barbiturate that is often used for nonpainful
diagnostic studies.
• A dose of 2.5 mg/kg should produce deep sedation
within 5 minutes, and effects should last between 30 to
60 minutes.
• Potential side effect is hypoxia and hypotension.

71. Hydroxyzine (Atarax, Vistaril)-
• It is a weak sedative, anticholinergic and antiemetic properties.
Absorption from Gastrointestinal tract is rapid.
• Clinical effect seen in 15 to 30 minutes, with peak levels at 2
hours and a mean half-life of 3 hours.
• Administration is preferably by the oral route.
Both the drugs are psychosedatives with an antihistaminic,
antiemetic, and antispasmodic effect.
Antihistaminic -
Hydroxyzine and Promethazine

72. • ADVERSE REACTIONS: Extreme drowsiness, xerostomia,
and hypersensitivity. In children paradoxical reactions may
occur at sedative doses.
• DOSAGE: Oral—1 to 2 mg/kg
Intramuscular (IM)—1.1 mg/kg

73. Promethazine (Phenergan)-
• Phenothiazine derivative. As a class phenothiazine are
most commonly used as antipsychotics, antiemetics, and
sedatives.
• Readily absorbed from the GI tract.
• Used as Antihistaminic, antiemetic, and sedative effects
since 1946 in US.

74. • Onset of action –
• 20 minutes and peak effect within 2-3 hrs.
• Should be used with caution in children with-
– Associated with enhanced risk of sudden infant death
syndrome (SIDS),
– sleep apnea,
– seizure-prone patients.
 It is effective in the management of children with only
lesser degrees of anxiety.

75. • ADVERSE REACTIONS: Dry mouth, blurred vision,
thickening of bronchial secretions, mild hypotension,
• DOSAGE: Oral/IM—0.5 to 1 mg/kg
SC—not recommended
Maximum recommended single dose is 50 mg.

76. Diphenhydramine (Benadryl)-
• Most commonly used antihistamines for procedural sedation and
antiemetic therapy in children.
• FDA approved for over the counter use as sleep aid and therapeutic
for motion sickness.
• Rapidly absorbed through the GIT, with maximum effect in 1 hour
and a duration of 4 to 6 hours.
• Metabolized by the liver and completely excreted in 24 hours.

77. • ADVERSE REACTIONS:
Disturbed coordination, epigastric distress, and
thickening of bronchial secretions.
• DOSAGE: Oral, IM, IV—1.0 to 1.5 mg/kg
Maximum single dose is 50 mg

78. Benzodiazepines-
Diazepam, Midazolam, Flumazenil
• Benzodiazepines are a group of medications most commonly
used for moderate sedation.
• In addition to their sedative properties, most benzodiazepines
have amnesic, anxiolytic, anticonvulsive and hypnotic effects.
• Commonly used benzodiazepines used for moderate sedation
include diazepam, lorazepam, flumazenil and midazolam.

79. • Diazepam (Valium)
• Rapidly absorbed from the GI tract ,onset of action within 15 to
30 minutes in children. High lipid solubility, metabolized into
two principle metabolites, desmethyldiazepam and oxazepam.
• Desmthyldiazepam is less potent causing secondary
drowsiness, or resedation, which may happen hours after the
initial dose.

80. SIDE EFFECTS:
Ataxia and prolonged sedation.
DOSAGE:
• Oral or rectal—0.2 to 0.5 mg/kg to maximum single dose of 10
mg , IV—0.25 mg/kg
(not recommended for children younger than 6 months of age.)

81. Midazolam (Versed, Hypnovel, Dormicum)-
• Midazolam is a first water soluble benzodiazepine.
• This property accounts for its stability in aqueous solution,
making it non irritating to the tissues following intravenous or
intramuscular administration.
• Onset of action- within 20-30 mins, allowing 30 mins
working time to the dentist.

82. • Midazolam may produce more consistent anterograde
amnesia during moderate sedation than does diazepam,
whereas diazepam is more likely to produce anxiolysis with
less amnesia.
DOSAGE:
• Oral—0.25 to 1.0 mg/kg to a maximum single dose of 20 mg
• IM—0.1 to 0.15 mg/kg to a maximum dose of 10 mg (15min)
• Commercial syrup available with the name - Syrpalta.

83. • The clinical use of midazolam is primarily reserved as
premedication/sedation drug, though it also has anticonvulsant and
muscle relaxant properties.
• One of the limiting factors in the use of midazolam for sedation is
the short length of action.
• So, midazolam can be used effectively in pediatric patients for short,
mildly painful and minimally invasive procedures.
Pakistan Oral & Dental Journal Vol 32, No. 3 (December
2012)

84. Some disadvantages of midazolam.
 Dependence upon patient compliance,
 Aborting sedation if a child splashes the drug out,
 Delayed onset of drug action, inability to titrate drug dose and
 difficulty in administrating a reversal agent or emergency drug in
the absence of a patent intravenous line.
 Some other disadvantages of oral route are;
 Unpredictable effect of the drug,
 variability in drug absorption across the gastrointestinal mucosa and
hepatic first pass effect.

85. Flumazenil (Romazicon)-
• Direct specific reversal agent used in clinical practice to treat
benzodiazepine overdose.
• Approved by FDA for intravenous administration.
• Effective and safe reversal in adults is achieved by titration, by the
injection of 0.2-mg doses every 3 to 5 minutes up to a total dosage
of 1 mg.

86. • When an adequate dose is achieved, reversal of effects occurs
within 2 minutes; however, the duration of reversal is short,
lasting only 20 to 45 minutes.
• For children, an initial intravenous dose of 0.01 mg/kg
(maximum dose: 0.2 mg) given over 15 seconds is
recommended,
• with repeat 0.01 mg/kg (maximum dose: 0.2 mg) after 45
seconds.

87. • In a study of adults undergoing moderate sedation with
benzodiazepines, Hosaka et al. found that a single dose of 0.2-
mg flumazenil was inadequate to reverse the effects of a typical
enteral sedation with triazolam.
• They concluded that reversal for the purpose of discharging the
patient early is neither appropriate nor safe.

88. OPIOIDS
• Opioids are most useful during moderate sedation for their ability to
suppress the cough reflex, provide analgesia, and produce a sensation
of well-being; however, direct scientific evidence for their utilization in
pediatric dental sedation is extremely limited.
• They are also closely linked with several important side effects,
including respiratory depression, nausea and vomiting, delayed gastric
emptying, constipation and urinary retention, and itching.

89. • Opioids differ from the benzodiazepines in several critical ways;
They produce analgesia by raising the threshold for perceiving
painful stimulation, whereas benzodiazepines have no significant
effect on pain perception.
• At sedative doses, opioids does not affect awareness and memory,
whereas benzodiazepines produce profound, dose-dependent
amnesia.
• Opioids used for moderate sedation/ analgesia include naloxone,
meperidine and fentanyl.

90. Fentanyl (Sublimaze)
• It is a potent synthetic opiate agonist, administered by parenteral,
transdermal, nasal, and oral routes.
• A dose of 0.1 mg is approximately equivalent to 10 mg of morphine
or 75 mg of meperidine.
• Fentanyl acts rapidly, and after intramuscular injection the onset
occurs in 7 to 15 minutes; duration of effects is 1 to 2 hours.
• The drug is metabolized by the liver and is excreted in the urine.

91. • Fentanyl can be administered by the intramuscular,
intravenous, or submucosal route.
• Supplied: 0.05 mg/mL in 2- and 5-mL ampules
• Dosage: 0.002 to 0.004 mg/kg

92. Mepridine (Demerol)
• It is a synthetic opiate agonist, closely related to fentanyl in
chemical structure. It is water-soluble but is incompatible with many
other drugs in solution.
• Meperidine may be administered through either enteral or parenteral
administration; however, oral administration is only about half as
effective as intramuscular injection.
• It is rapidly and well absorbed from the GI tract, reaching peak
effect in about 60 minutes.

93. • Its use is contraindicated in patients with a history of hepatic
disease, renal disease or dysfunction, or seizure disorders.
• Supplied: oral tablets—50 and 100 mg; oral syrup—50 mg/5
mL; parenteral solution—25, 50, 75, and 100 mg/mL
• Dosage: oral, subcutaneous, or intramuscular—1.0 to 2.2
mg/kg, not to exceed 100 mg when given alone or 50 mg when in
combination with other CNS depressants

94. Naloxone (Narcan)
• A semisynthetic opioid receptor antagonist used to reverse the
effects of opioid drug overdose, naloxone is a pure antagonist,
with no intrinsic agonist activity.
• Following subcutaneous or intramuscular injection, reversal
begins within 2 to 5 minutes, as compared with 30 seconds to 2
minutes following intravenous administration.

95. • Excessive or too rapid reversal may result in adverse reactions
including nausea, vomiting, sweating, hypotension,
hypertension, ventricular tachycardia and fibrillation, and
pulmonary edema.
• Dosage: intravenous, subcutaneous, intramuscular— initial dose:
0.01 mg/kg; subsequent doses: 0.1 mg/kg (2 mg maximum)
every 2 to 3 minutes
• Supplied: parenteral solution—0.02, 0.4, 1.0 mg/kg

96. OTHER SEDATIVE-HYPNOTICS
• These include paraldehyde, chloral hydrate, ethchlorvynol,
meprobamate, and others.
• The effects of all of these drugs resemble those of barbiturate drugs,
in that they produce profound hypnosis with little or no effect upon
pain perception.
• The last of these agents to be used routinely in clinical practice was
chloral hydrate, which was used by many pediatric dentists until it
was discontinued in 2012.

97. CHLORAL HYDRATE
• Is an aldehyde compound that is metabolized by alcohol
dehydrogenase in the liver to its active metabolite, trichloroethanol.
• It is a chemical irritant to the skin and mucous membranes and is
associated with a high rate of nausea and vomiting, particularly
when administered on an empty stomach.

98. • After oral administration, the drug was characterized by a slow
onset time (30 to 60 minutes) and had a duration of action of 4 to 8
hours, with an elimination half-life of 8 to 11 hours.
• Children given chloral hydrate would often enter a period of
disinhibition resulting in excitement and irritability before reaching
a level of clinically useful sedation.
• No longer available commercially in the United States,

99. CS vs GA
 The AAPD approves the use of general anesthesia in pediatric
dentistry under the following conditions:
• patients who are not capable of cooperation,
• patients who have been submitted to local anesthesia which was
inefficient,
• extremely anxious children,

100. • who are excessively afraid and incapable of communicating,
• patients that need significant surgical procedures,
• in order to prevent psychological trauma and to decrease
health risks, and Dental procedures that require immediate
action.

102. • In conscious sedation, Verbal contact with the patient must be
always maintained throughout the period of sedation,
• which means that it is a medically controlled state of depression of
conscience that allows the patient to preserve his protective
reflexes,

103. • A free respiratory airway and also present an appropriate response
to physical stimulus and verbal commands such as, e.g., “open your
mouth”.
• Drugs and techniques used for conscious sedation during dental
treatment must present a sufficient safety margin so that loss of
conscience can be expected to be a completely unlikely event.

104. Conscious sedation vs general anesthesia in pediatric
dentistry – a review, Silva CC et al MEDICALEXPRESS
2015;2(1):M150104

105. CONCLUDINGTHOUGHTS
• Conscious sedation is a technique meant for dealing with dental
phobia and should not be considered an alternative to effective local
anesthesia or good behavioral management.
• Route of administration and the drug should be selected on an
individual patient basis. Importance of adequately trained staff
in an area adequately equipped with monitoring tools along with
importance of detailed pre sedation assessment cannot be
overemphasized.
• When practicing sedation in a dental setting,
awareness of limitations is necessary.

106. REFERENCES
• Mc-Donald and Avery 10th edition.
• Handbook of nitrous oxide sedation and oxygen sedation.4th edition. Morris S.
Clark and Ann L. Brunick.
• Textbook of pediatric dentistry S.G Damle 4th edition.
• American Academy of Pediatric Dentistry. Clinical guideline on the elective use
of conscious sedation, deep sedation, and general anesthesia in pediatric dental
patients. Pediatr Dent. 2004;25:95-103.
• Krishna Priya V1, Divya Gaur2, Mayuri Ganesh2, Santosh Kumar
Ch3.Conscious Sedation in Pediatric Dentistry: A Review . International
Journal of Contemporary Medical Research. Volume 3 | Issue 6 | June 2016
• Nisha Singh1, Chandan R Agali2, Ashok KN3, N Senthil Kumaran4, Geetha
L5, Saraswati Ghosh6 . Application of Conscious Sedation in Dentistry . J Dent
Med Res 2014;1(4):90-93.
• EAPD Guidelines on Sedation in Paediatric Dentistry

107. • THANK YOU !!!