Conscious Sedation: Emerging Trends in Pediatric Dentistry

A Narrative Review of the Efficacy and Safety of Oral Ketamine in Pediatric Sedation: A Critical Analysis of Current Evidence

Sedation in pediatric patients presents unique challenges due to their developmental and physiological differences compared to adults. Oral ketamine, a dissociative anesthetic, has emerged as a promising alternative to traditional sedatives, offering a non-invasive method for achieving sedation in children. This comprehensive review evaluates the efficacy and safety of oral ketamine for pediatric sedation, consolidating evidence from recent studies and clinical trials. The review details the pharmacological properties of oral ketamine, including its mechanism of action and its role in achieving effective sedation. It examines dosing guidelines, clinical applications, and the outcomes of sedation procedures utilizing oral ketamine. Additionally, the review addresses the safety profile of oral ketamine, including standard and serious adverse effects, and provides recommendations for monitoring and managing potential risks. Comparative analyses with other sedation methods highlight the advantages and limitations of oral ketamine, including its effectiveness and ease of administration compared to intravenous (IV) and inhaled sedatives. The review also identifies gaps in the current literature and suggests areas for future research, including long-term safety and potential developmental impacts. In conclusion, oral ketamine represents a valuable option for pediatric sedation, offering a balance of efficacy and ease of use. This review aims to guide clinicians in making informed decisions regarding the use of oral ketamine, contributing to safer and more effective sedation practices in pediatric care.

Efficacy of continuous intravenous remimazolam versus midazolam in the extraction of impacted wisdom teeth: protocol of a randomised controlled trial

INTRODUCTION

Benzodiazepines such as midazolam are widely used to moderately sedate patients during impacted wisdom tooth extraction to reduce anxiety in outpatient surgery. This present protocol was designed to determine whether continuous intravenous remimazolam, a new ultrashort-acting benzodiazepine, produces superior postoperative recovery quality to that of midazolam in patients undergoing extraction of impacted wisdom teeth.

METHODS AND ANALYSIS

This study is a multicentre randomised controlled trial conducted at Peking Union Medical College Hospital, Beijing Anzhen Hospital and Beijing Shijitan Hospital in China. Approximately 150 participants undergoing extraction of impacted mandibular wisdom teeth will be randomly allocated to two groups (remimazolam and midazolam). The participants will be administered standard interventions to ensure they achieve a sedation level of III on the Ramsay sedation scale during the treatment. Preoperative and anaesthesia management and surgical techniques will be standardised for all participants. The primary outcome is recovery time for complete alertness and the secondary outcomes are anterograde amnesia during and after surgery, and interruption during operation for poor compliance or safety concerns.

ETHICS AND DISSEMINATION

This study has been approved by the Ethics Review Committee of Peking Union Medical College Hospital (approval number: ZS-3142), Beijing Anzhen Hospital (approval number: KS2022082) and Beijing Shijitan Hospital (approval number: 2023-4).

TRIAL REGISTRATION NUMBER

NCT05350085.

Advantages of Sedation With Remimazolam Compared to Midazolam for the Removal of Impacted Tooth in Patients With Dental Anxiety

PURPOSE

Although midazolam is commonly used to sedate patients with dental anxiety, it has shortcomings that reduce the satisfaction of patients and doctors. The aim of this study was therefore to explore the advantages of remimazolam as a sedative.

METHODS

The study design was a prospective randomized controlled trial. Patients with dental anxiety and who were to undergo impacted tooth removal were randomized into remimazolam and midazolam groups. They were sedated with remimazolam or midazolam prior to receiving nerve blocker. The predictor variable was the type of sedative, while the primary outcome variables were the onset time, awakening time, recovery time, and postoperative side effects. Secondary outcome variables were the Modified Dental Anxiety Scale score before and after surgery, patient satisfaction and comfort levels scores, and doctor satisfaction level scores. Other variables included the patient demographics and the operation time. Data were analyzed using the Student's t-test, Mann-Whitney test, χ² test, and two-way repeated measurement ANOVA test (SPSS Version 25.0).

RESULTS

A total of 83 patients were included in this study, with 42 randomized to the remimazolam group and 41 to the midazolam group. There were no significant differences between the two groups in terms of demographic features and operation time. Patients in the remimazolam group had significantly shorter onset time, awakening time, and recovery time compared to those in the midazolam group (each P < .001). Postoperative side effects were more frequent in the midazolam group (P < .001). Following surgery, the Modified Dental Anxiety Scale scores in both groups were significantly lower than prior to surgery (P < .001). Satisfaction levels scores for the patients and doctor were higher in the remimazolam group than in the midazolam group (P < .001).

CONCLUSIONS

The use of remimazolam results in faster onset, more rapid recovery, and lower incidence of postoperative side effects compared to midazolam, leading to improved satisfaction for patients and doctors. Remimazolam therefore appears to have several advantages over midazolam for the sedation of patients with dental anxiety associated with the removal of impacted teeth.

Safety and efficacy of target controlled infusion administration of propofol and remifentanil for moderate sedation in non-hospital dental practice

Background

Fearful and anxious patients who find dental treatment intolerable without sedative and analgesic support may benefit from moderate sedation. Target controlled infusion (TCI) pumps are superior to bolus injection in maintaining low plasma and effect-site concentration variability, resulting in stable, steady-state drug concentrations. We evaluated the safety and efficacy of moderate sedation with remifentanil and propofol using TCI pumps in non-hospital dental settings.

Methods

A prospective chart review was conducted on 101 patients sedated with propofol and remifentanil using TCI pumps. The charts were completed at two oral surgeons and one general dentist's office over 6 months. Hypoxia, hypotension, bradycardia, and over-sedation were considered adverse events and were collected using Tracking and Reporting Outcomes of Procedural Sedation (TROOPS). Furthermore, patient recovery time, sedation length, drug dose, and patient satisfaction questionnaires were used to measure sedation effectiveness.

Results

Of the 101 reviewed sedation charts, 54 were of men, and 47 were of women. The mean age of the patients was 40.5 ±18.7 years, and their mean BMI was 25.6 ± 4.4. The patients did not experience hypoxia, bradycardia, and hypotension during the 4694 min of sedation. The average minimum Mean Arterial Pressure (MAP) and heartbeats were 75.1 mmHg and 60.4 bpm, respectively. 98% of patients agreed that the sedation technique met their needs in reducing their anxiety, and 99% agreed that they were satisfied with the sedation 24 hours later. The average sedation time was 46.9 ± 55.6 min, and the average recovery time was 12.4 ± 4.4 min. Remifentanil and propofol had mean initial effect-site concentration doses of 0.96 µ/ml and 1.0 ng/ml respectively. The overall total amount of drug administered was significantly higher in longer sedation procedures compared to shorter ones, while the infusion rate decreased as the procedural stimulus decreased.

Conclusion

According to the results of this study, no patients experienced adverse events during sedation, and all patients were kept at a moderate sedation level for a wide range of sedation times and differing procedures. The results showed that TCI pumps are safe and effective for administering propofol and remifentanil for moderate sedation in dentistry.

Establishment of an intravenous conscious sedation service at a University Dental Clinic in Tanzania

Background

With advances in safety measures for anesthesia, conscious sedation has gained popularity in the field of dentistry and has become essential in dental practice worldwide. However, in Tanzania, intravenous (IV) sedation is rarely practiced in the dental field. Therefore, we report the establishment of sustainable IV conscious sedation in dental practices and subsequently train local OMS residents in Tanzania.

Methods

In 2019, intravenous conscious sedation was initiated at the University Dental Clinic of the Muhimbili University of Health and Allied Science (MUHAS), Tanzania. During the preparatory phase of the program, local oral and maxillofacial surgeons (OMSs) were given a series of lecture notes that concentrated on different aspects of IV conscious sedation in dentistry. During the on-site training phase, an oral surgeon from the United States joined the OMSs for case selection, IV-conscious sedation procedures, and patient follow-up. Patients were recruited from existing patient records at the MUHAS Dental Clinic.

Results

The first conscious IV sedation program in dentistry was successfully launched at the University Dental Clinic in Tanzania. The local team of OMSs was trained on the safe administration of sedative agents (midazolam or ketamine) to perform various minor surgical procedures in a dental office. Nine patients with different ages, body masses, and medical conditions benefited from the training. No complications were associated with IV conscious sedation in the dental office.

Conclusion

This was the first successful "hands-on" training on IV conscious sedation provided to OMSs in Tanzania. It laid the foundation for the sustainable care of patients with special needs requiring oral health-related care in the country.

Ambulatory Sedation for Dental Procedures-Case of Cuenca, Ecuador

In recent years, the dental treatment of children under sedation and/or general anesthesia on an outpatient basis has been developed as a behavioral management model in pediatric dentistry. The objective of this study was to establish the percentage of pediatric patients who required deep sedation on an outpatient basis in dental offices in the city of Cuenca, Ecuador. An observational study was conducted with a sample of 450 records of school- and preschool-age patients, where the variables were type and time of treatment, age, and sex. Statistical data were analyzed using the statistical program SPSS V.27 (IBM, Armonk, NY, USA). The highest percentage of children who received sedation were of preschool age. In general, there were three types of procedures per session, the most frequent being restorations (67%), followed by pulp treatment (49.8%) and, less frequently, minor surgery. The need for sedation for dental procedures is high in preschool patients, and ambulatory sedation has contributed to meeting this need. However, a regulation for its use is required at a national level.

Case Report: Applicability of sedation with nitrous oxide in the management of molar incisor hypomineralization in pediatric patients

Patients with molar-incisor hypomineralization (MIH) may manifest tooth hfypersensitivity and difficulties in undergoing dental treatment, including fear, anxiety, and behavior problems in the dental office. Then, the objective of this study was to report a clinical case series using inhalation sedation with nitrous oxide and oxygen as a clinical strategy in the management of MIH pediatric patients during dental treatment. Pediatric patients and their legal guardians were properly informed and data were extracted from clinical charts. Six clinical cases were included, whose patients were between 8 and 12 years old. Of these, 4 were female. The indication of moderate sedation took into account the clinical difficulties related to patients with MIH, such as obtaining anesthesia and cooperation, in addition to odontophobia and dental anxiety. All patients were carefully examined to undergo the sedation technique, including medical history and previous experiences with nitrous oxide inhalation sedation, as well as the vital signs were properly evaluated before, during and after the procedures. The nitrous oxide concentration ranged between 30% and 60%. The procedures were restorative, endodontic or surgical (extractions). In general, the use of sedation contributed to the performance of dental procedures. The use of inhaled sedation helped in behavioral management and during the treatment, increasing the effectiveness of local anesthesia. Patients were cooperative for treatment, while no adverse effects or complications related to sedation were observed. Thus, for the patients in this case series, the use of inhalation sedation with nitrous oxide and oxygen contributed to the clinical management of patients with MIH.

The Efficacy and Complications of Deep Sedation in Pediatric Dental Patients: A Retrospective Cohort Study

Background

Dental anxiety in children is a common problem. Currently, many of dental procedures are performed under sedation. Different methods of sedation have been employed for this purpose. Compared to adults, children usually need a deeper sedation level. The aim of this retrospective study is to assess the efficacy and complication of deep sedation in pediatric dental patients.

Method

This study was performed on 250 ASA (American Society of Anesthesiologists) I, II children undergoing deep sedation during the dental procedures. After the administration of oral midazolam as premedication, the monitoring process started. The patients that received the sedation dose of propofol and oxygen through nasal cannula during the procedure were carefully monitored for the purpose of evaluating hemodynamic and respiratory complications. The mean procedure and recovery time, postoperative nausea and vomiting (PONV), and success rate were further studied.

Result

The average age of the patients was 3.7. 32% of the patients were females, and 68% of them were males. Laryngospasm that occurred in 5 cases was resolved immediately by using positive pressure ventilation. Mild hypoxia was observed in 17 cases which were immediately managed by a bag-valve-mask ventilation. No cases of hemodynamic complications and PONV were reported. The mean length of the procedure was 57 minutes, and the mean length of recovery was 16 minutes. The success rate of this method was estimated to be 99.6%.

Conclusion

Deep sedation with propofol is a suitable technique with a high success rate for dental procedures in children. It was also concluded that in pediatric dental procedures, the presence of a skilled anesthetist and the implementation of a close monitoring process are required.

Comparison of two Intranasal Sedatives, Midazolam versus Dexmedetomidine, in Children with High Dental Fear: a Randomized Clinical Trial

STATEMENT OF THE PROBLEM

Pharmacologic management of uncooperative behavior is a growing trend in dentistry. Determining the most appropriate drug, route of administration, and proper candidate for sedation have been the goal of several investigations.

PURPOSE

The aim of this study was to compare the sedative effect of intranasal (IN) sedation of midazolam (MDZ) in compare to dexmedetomidine (DEX) while taking into consideration the effect of dental fear, and psychological status on sedation success.

MATERIALS AND METHOD

This double-blind randomized clinical trial included 92 uncooperative dental patients aged 4-6. Study participants were randomly assigned to receive either 0.2mg/kg IN MDZ or 1µg/kg DEX. Sedation was evaluated using the Houpt sedation rating scale. Vital signs were recorded before and during sedation. Prior to sedation, the level of dental fear was determined through children's fear survey schedule-dental subscale (CFSS-DS). Psychological characteristics were screened using the strengths and difficulties questionnaire (SDQ). Data were analyzed using T-test, Mann-Whitney, Chi-square, and repeated-measures analysis of variance (ANOVA).

RESULTS

Overall ratings of sedation and subscales of sleep, crying, and movement were comparable between groups (p> 0.05); however, more acceptable behavior (overall scores (4+5+6) was observed in MDZ group compared to DEX group (64% vs. 47.7%) (p= 0.007). All participants were found to have abnormal levels of dental fear (CFSS-DS≥38). However, according to SDQ, the study participants have mainly shown normal behavioral status. A significant association was found between dental fear and sedation success (MDZ, p= 0.001, DEX, p= 0.03), while similar findings were not observed for psychological characteristics (MDZ, p= 0.09 and p= 0.41; DEX, p= 0.71 and p= 0.53). Physiological parameters remained within normal limits in both groups.

CONCLUSION

Sedation with IN MDZ resulted in overall behaviors, which were more satisfactory in highly fearful pediatric dental patients. Despite baseline uncooperative behaviors, the psychological status of study participants were close to average and were not associated with sedation failure.

Children's Attitudes and Behaviors about Oral Health and Dental Practices

The present study sought to contribute to a better understanding of children's attitudes and behaviors regarding oral health and dental practices. The sample was composed of 101 children (8-10 years), collected from several schools in the Lisbon metropolitan area. Our main goals were to collect a survey of information about the beliefs, attitudes, habits and knowledge of children about oral and dental issues in order to not only have an overview of them but also to serve as a basis and a starting point for the development of intervention programs to increase positive attitudes and behaviors related to oral health and promote greater knowledge about these subjects. In general, children reported positive behaviors regarding dental habits and oral hygiene practices. Children's opinions and beliefs about dentists were also globally positive; however, the results suggested that younger children reported more positive attitudes, emotions and previous experiences. Regarding children's knowledge about these dental issues, the results were quite negative and worrying, ruled by ignorance and incorrect beliefs and behaviors. In sum, all the results and conclusions of this study may contribute to the development of educational programs within the scope of the promotion of oral health and hygiene practices-"An Adventure about Oral Health."

A case series analysing patients with dental anxiety: a patient-centered model based on psychological profiling

Anxiety and distress can jeopardize dental care experience of patients and may affect the clinical result. Although a wide range of sedation and analgesia techniques are currently available to relieve distress and pain during dental procedures, operative models to choose the most effective sedation-analgesic strategies are still insufficient.

This case series proposes a patient-centered model to optimize patients’ cooperation during dental care delivery. We describe how to achieve correct anaesthesia by using the least sedative procedure, accounting for the dental procedure needed and patient’s psychological profile.

Five patients were considered as paradigmatic to show the balance between patients’ subjective experiences and the clinical procedures: a patient with low stress, good compliance (case 1); a patient with moderate stress and reduction in compliance (case 2); anxious patient (case 3); a patient with acute anxiety and emotional distress (case 4); anguished patient (case 5).

A multimodal treatment of emotional and behavioural condition and a patient-centered model approach contributed to achieve the best patient satisfaction in the five cases detailed here.

Mobile Dental Delivery System: An Effective Protocol for Hygiene and Disinfection

Mobile dental delivery systems (MDDSs) are receiving growing interest for reaching isolated patients, as well as in dental care for fragile and hospitalized patients, with the advantage of being able to be used from room to room or during general anesthesia (GA) in an operating room. Therefore, ensuring the care safety is crucial. The aim of this study was to elaborate and assess an MDDS maintenance protocol, containing the management of dental unit waterlines and adapted to specific conditions such as dental care under GA. A step-by-step protocol was established and implemented for an MDDS used during dental care under GA in children. Samples of the output water were collected at J0, J+1, 3, 6, 12, and 24 months, and cultured to observe the microbiological quality of the water. All the results (heterotrophic plate count at 22 °C, at 37 °C, and specific pathogenic germs sought) showed an absence of contamination. The protocol presented was effective over time and allowed ensuring the safety of care to be ensured when using MDDS, even during dental procedures under GA. As a result, it could be implemented by any dental care delivery structure wanting to reinforce the safety of its practice.

Safety and effectiveness of chloral hydrate in outpatient paediatric sedation for objective hearing tests

OBJECTIVES

Chloral hydrate is a sedative that has been used for many years in clinical practice and, under proper conditions, gives a deep and long enough sleep to allow performance of objective hearing tests in young children. The reluctance to use this substance stems from side effects reported over time that can vary, depending on dose, procedure settings and immediate life supporting intervention when needed. Our study adds to those that have appeared in recent years, showing that chloral hydrate is an effective and safe substance when is used in proper conditions.

METHODS

The study included 322 children who needed sedation for objective hearing tests, from April 2014 to March 2018. Parents were instructed to bring the child tired and fasted for at least 2 h before sedation. The sedative was administered by trained staff in the hospital, and the child was monitored until awaking.

RESULTS

In our study group, over half of the children were in the age 1-4 years group, and only 15% were older than 4 years. The dose of chloral hydrate ranged between 50 and 83 mg/kg body weight, with an average of 75 mg. Successful sedation occurred in 94.1% of children; 0.9% of children awoke during testing and required supplemental sedation or rescheduling of the testing. The most common side effects were vomiting, agitation, prolonged sleep, and failure to fall asleep.

CONCLUSIONS

Comparing the side effects of chloral hydrate in our study with those from other studies, ours were similar to those described in the literature. In our study chloral hydrate was effective and had only limited adverse effects. The use of chloral hydrate under hospital conditions with proper monitoring could be a practical and safe solution for outpatients or those with short-term hospitalisation.

A Comparative Study on Efficacy and Safety of Propofol versus Dexmedetomidine in Sleep Apnea Patients undergoing Drug-Induced Sleep Endoscopy: A CONSORT-Prospective, Randomized, Controlled Clinical Trial

The aim of this study is to compare the efficacy and safety of propofol with dexmedetomidine in patients with obstructive sleep apnea hypopnea syndrome (SAHS) undergoing drug-induced sleep endoscopy (DISE). The 88 patients diagnosed with SAHS in the Affiliated Hospital of Xuzhou Medical University were randomly allocated into 2 groups (n = 44). Patients in the group dexmedetomidine (group D) received continuous intravenous infusion of dexmedetomidine 1 μg/kg over 15 minutes before the endoscopy, and propofol 2 mg/kg was intravenously administrated in the group propofol (group P). Cardiopulmonary parameters of patients were recorded. The time to fall asleep, duration of endoscopic examination, the wakeup time of patients, the number of mask ventilations for patients, the satisfaction of patients and endoscopic performers, and false positive cases of SAHS of patients were compared between the two groups. Compared with group D, mean arterial pressure (MAP) and blood oxygen saturation (SPO₂) of patients in the P group were lower at the time point of T1 (P < 0.05), the duration of endoscopic examination and wakeup time of patients were obviously prolonged, the incidence of mask ventilation for patients and false positive cases of SAHS of patients was observably higher, and the satisfaction of endoscopic performers was markedly lower, but the time to fall asleep was significantly shortened (P < 0.05). Dexmedetomidine served as a novel sleep induced drug and can provide satisfactory conditions and be safely and effectively applied for endoscopy in patients with SAHS, without adverse hemodynamic effects.

The Level of Dental Anxiety in Students of the First Year of Studies From Lublin Universities

Dental anxiety is a very important factor affecting the efficacy of prevention, diagnosis and treatment of dental diseases, both in patients in the developmental age and in young adults. Anxiety is considered an emotional state with negative connotations. The aim of the study was to determine the level of dental anxiety in first year university students, the intent being to help to develop an individual treatment plan in this group of patients. The study involved 280 students including 230 females and 50 males. Of these, 122 patients were from the Medical University of Lublin, 79 from University of Life Sciences and 79 from University of Maria Curie-Skłodowska. The mean age of the study subjects was 21 years and 8 months ± 3,9 months. No differences in the level of dental anxiety between women and men were observed. The highest level of dental anxiety was observed among students of University of Life Sciences, while the lowest level was observed among students of the Medical University

Intranasal Premedication Effect of Dexmedetomidine Versus Midazolam on the Behavior of 2-6-Year-Old Uncooperative Children in Dental Clinic

OBJECTIVES

The aim of this study was to compare the intranasal premedication effect of newly introduced dexmedetomidine (DEX) versus midazolam on the behavior of uncooperative children in the dental clinic.

MATERIALS AND METHODS

This crossover double-blind clinical trial was conducted on 20 uncooperative children aged 2-6 years who required at least two similar dental treatment visits. The subjects were randomly given 1 μg/kg of DEX and 0.5 mg/kg of midazolam via the intranasal route. For the sedation protocol in the two groups, 0.25 mg/kg of atropine in combination with 0.5 mg/kg of midazolam added to 1-2 mg/kg of ketamine were used 30 minutes after premedication and transferring the patient to the operating room. Dental treatments were carried out by a pediatric dentist blinded to the type of the administered premedication. The sedative efficacy (overall success rate) of the agents was assessed by two independent pediatric dentists based on the Houpt scale. Data analyses were carried out according to Wilcoxon signed-rank test and paired t-test.

RESULTS

There were no significant differences in the premedication efficacy of intranasal DEX and midazolam according to the Houpt scale (P>0.05).

CONCLUSIONS

Intranasal midazolam and DEX are satisfactory and effective premedication regimens for uncooperative children.

Conscious Sedation in Dentistry

Sedation in dentistry has been a controversial topic due to questions being raised over its safety, especially in dental chair. Dental fear and anxiety are not only common in children but also significantly prevalent among adults due to high intensity of pain. Sharing of airway between the anesthesiologist and the dentist remains the greatest challenge. The purpose of this review is to study the recent trends in conscious sedation in the field of dentistry from an anesthesiologist's perspective. It will provide a practical outline of the pharmacokinetics, pharmacodynamics, and routes of administration of the drugs or gases used.

Dexmedetomidine-based monitored conscious sedation combined local anesthesia for levator resection in a 10-year-old child with Marcus Gunn jaw-winking synkinesis: A case report

RATIONALE

Levator resection has become a routine procedure for patients with severe Marcus Gunn jaw-winking synkinesis (MGJWS). To optimize the surgical outcome, adult patients need to be kept awake, or easily aroused and responsive to verbal commands during the operation. However, levator resection is commonly performed under general anesthesia in pediatric patients. In the present case, we described a successful anesthetic protocol of conscious sedation with local anesthesia for levator resection in a child.

PATIENT CONCERNS

A 10-year-old boy with MGJWS was admitted to our hospital and scheduled for levator resection. The patient was born through a normal delivery and had no previous history of allergy, no comorbidity, and no history of receiving anesthesia or operation. The laboratory tests of the patient were unremarkable.

DIAGNOSES

The diagnosis of MGJWS was made by two experienced ophthalmologists.

INTERVENTIONS

A 10-year-old boy with MGJWS was admitted to our hospital and scheduled for levator resection. The levator resection was performed under monitored conscious sedation with dexmedetomidine and local anesthesia.

OUTCOMES

Patient with spontaneous breathing responded normally to verbal commands throughout the operation, and no adverse events occurred. The patient and ophthalmologist reported high satisfaction with anesthesia management.

LESSONS

Dexmedetomidine-based monitored conscious sedation with local anesthesia is a feasible alternative to general anesthesia for levator resection in collaborative patients.