Dental Update - Overview of paediatric dental sedation: 1. current UK guidelines

Abstract

The use of conscious sedation in paediatric dentistry is very beneficial for the management of anxious children. It is essential that it is provided according to national guidelines in a safe and effective manner.

Clinical Relevance: Dentists carrying out conscious sedation in children must be aware of current national guidance and the most appropriate techniques to use.

Article

Providing dental treatment for children can often present a challenge if the child is anxious and fearful or if a potentially difficult procedure is required. The use of conscious sedation in these patients can be of great benefit.

The intention of this paper is to review the main areas of current UK guidelines for the use of conscious sedation for paediatric dental patients. The reader is directed to the individual guidelines for more detailed information.

Sedation guidelines

Guidelines have been produced to ensure sedation is provided in a safe and effective manner with the appropriate facilities, equipment, staff and training available. There are three main sets of guidance pertaining to paediatric dental sedation:

The main guidelines pertaining to the use of conscious sedation in the UK were produced by the Standing Dental Advisory Committee (SDAC) for the Department of Health in 2003,1 supported by The General Dental Council in their 2005 document Standards for Dental Professionals 2005.2 The guidance advises the use of nitrous oxide and oxygen as the standard technique for children.

In 2007, a further document was published providing guidance on the use of alternative sedation techniques in dentistry with some changes to the definition of standard techniques. The advice given was that intravenous midazolam with the single drug midazolam was considered to be a standard technique, for patients 12 years of age and over, provided it was administered by appropriately trained and experienced dental practitioners.3

In October 2010, the National Institute for Clinical Excellence (NICE) published guidelines entitled Sedation in Children and Young People – Sedation for Diagnostic and Therapeutic Procedures in Children and Young Adults.4 The document considered the provision of sedation in all fields of medicine. There are many generic aspects considered but recommendations specifically for dental procedures are limited. It is therefore pertinent that dental professionals continue to refer to the guidance laid out in 2003 and 2007 documents referred to above. 1^,3

The SDAC document considers a child to be anyone under the age 16 years, of normal mental and physical development, with the understanding that age of maturity is variable and due discretion should be exercised.

All the aforementioned guidance documents consider similar principles in the provision of conscious sedation in children and each subject area will be addressed with reference to the available literature.

Definition of conscious sedation

Conscious sedation has been defined as:

‘A technique in which the use of a drug or drugs produces a state of depression of the central nervous system enabling treatment to be carried out, but during which verbal contact 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.’1

When undertaken in children it is important that:

‘Conscious sedation must only be undertaken by teams that have adequate training and experience in case selection, behavioural management and administration of sedation for children and only in an appropriate environment.1

Main elements of the guidelines for paediatric sedation

Drugs and technique

With regard to the sedation drugs and techniques for paediatric sedation, it is recommended that nitrous oxide/oxygen inhalation sedation should be the first choice for children who are unable to tolerate treatment with local anaesthetic alone and where more complex or invasive procedures are planned.1-3

Intravenous sedation may be appropriate in a minority of cases, particularly where inhalation sedation has been unsuccessful and ‘should only be provided by those trained and experienced in sedation for children and in the administration of intravenous drugs’.1 The 2007 guidelines recommend that intravenous midazolam sedation may be used in children 12 years and over, provided the aforementioned criteria are met.3

With regard to oral and transmucosal sedation, the SDAC guidance recommends that these should: ‘only be administered under appropriate circumstances by a practitioner experienced in their use.’ It is important also that the practitioner is competent in intravenous cannulation.1

Education and training

All members of the dental team providing conscious sedation must have received appropriate theoretical, practical and clinical training. The subject areas which should be covered are given in Table 1.

Table 1. Subject areas relevant to conscious sedation.

The pharmacology of sedation drugs;

Applied physiology;

Assessment of children and young people;

Administration of sedation;

Monitoring during sedation;

Care of the patient during recovery;

Management of complications, including paediatric life support.

Documented up-to-date evidence of competency should be kept by healthcare professionals delivering sedation to include:

Satisfactory completion of a theoretical training course on the principles and practice of sedation; and

A comprehensive record of practical experience of sedation techniques used.

Environment and equipment for sedation

Treatment and recovery areas must be large enough for the dental team. Appropriate sedation and resuscitation equipment must be readily available.

Patient assessment

Ensure trained healthcare personnel carry out a pre-sedation assessment and document the results in the patient's records.

To establish suitability for sedation the following areas should be considered:4

Current medical condition;

Weight (growth assessment);

Past medical problems;

Current and previous medication;

Physical status (including airway);

Psychological and developmental status.

It is advised to seek advice from a specialist (eg consultant anaesthetist) if:

There is concern about the airway or breathing problems; or

If the patient is assessed as American Society of Anesthesiologists (ASA) grade 3 or greater.5

Suitability of sedation technique

When deciding on the most suitable sedation technique, the following factors should be considered:

What procedure is to be undertaken;

The level of sedation required;

Any contra-indications to sedation;

Possible side-effects;

Patient (or parent/carer) preference.

Informed consent

To allow the patient and his/her parents or carer to make an informed decision about the type of sedation he/she receives, verbal and written information should be provided (Figure 1).

Figure 1. Providing verbal and written information.

The information should include:

The proposed sedation technique;

The alternative to sedation;

Associated risks and benefits;

Pre- and post-operative instructions.

Written informed consent should then be documented.

Monitoring

Inhalation sedation

Clinical monitoring of the patient without additional electronic devices is generally adequate.

Intravenous, oral and transmucosal sedation

Clinical monitoring is more rigorous, particularly for children, and it is worth noting the recommended procedures as stated in the NICE document 2010.4

For conscious sedation, excluding with nitrous oxide and oxygen alone, the vital signs that should be continuously monitored are given in Table 2. It is also advisable to monitor blood pressure as long as this does not stress the child unduly. All monitoring details must be clearly recorded in the patient's notes.

Table 2. Vital signs to be monitored.

Depth of sedation;

Respiration;

Oxygen saturation;

Heart rate;

Pain;

Distress.

Recovery and discharge

On completion of the procedure, under conscious sedation, monitoring should continue until the patient is stable and fit to be discharged. Before the patient is discharged, the following criteria should be met:

Vital signs have returned to normal levels;

The patient is fully awake;

Any nausea and pain have been adequately managed.

Conclusion

The guidance documents relating to conscious sedation for dentistry aim to promote safe and effective care. Before choosing to carry out treatment under sedation, it is imperative that the team, including clinician, sedationist and nurses, is fully conversant with the techniques being used and the patient is being managed in the most appropriate environment. It is essential to consider each patient on an individual basis, taking into account his/her needs and suitability for the sedation techniques proposed; comprehensive documentation of all stages of the patient journey must be recorded in the clinical notes.

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References

Overview of paediatric dental sedation: 1. current UK guidelines

Authors

Katherine E Wilson