Pediatric Dentistry Pharmacology: Managing Pain & Anxiety
PHARMACOLOGY IN PEDIATRIC DENTISTRY
PAIN AND ANXIETY
Most pediatric dental patients can be treated with conventional techniques and behavior management. However, some cases require additional pain and anxiety control.
Drug therapy is used for children who cannot be treated with traditional behavior management and local anesthesia.
CONSCIOUS SEDATION
Definition: A minimally depressed level of consciousness where the patient can maintain airway patency, respond to stimuli, and follow commands.
Conscious Sedation Levels:
- Light Sedation (oral)
- Sedation with nitrous oxide (inhaled)
- Deep Sedation (rectal, nasal, or IM)
General Anesthesia
SPECIAL CONSIDERATIONS
MONITORING IN CONSCIOUS SEDATION
- Pulse Oximeter
- Precordial Stethoscope
- Blood pressure cuff
Deep sedation prevents easy awakening and intentional response to verbal commands.
Properly applied conscious sedation with monitoring ensures adequate cardiovascular and respiratory function. Loss of protective reflexes and airway maintenance can lead to apnea or hypoxemia, posing danger.
OBJECTIVES OF CONSCIOUS SEDATION
- Reduce anxiety and create a safe, comfortable environment for treatment.
- Minimize movements and reactions during treatment.
- Increase patient cooperation and tolerance for lengthy procedures.
- Assist in treating physically and psychologically compromised patients.
CONSIDERATIONS
- Pre-operative behavioral assessment
- Pre-operative oral and general health assessment
- Parental collaboration, involvement, and consent
- Economic considerations
- Treatment alternatives
- Staff and professional training and experience
CONSCIOUS SEDATION INDICATIONS
- Patients with pre-existing conditions:
- Mild psychiatric or mental disorders
- Moderate spastic muscle disorders
- Patients with dental phobia or uncooperative children
- Post-surgical cases
- ASA I and II patients
Patients with local anesthetic intolerance or severe physical/mental disabilities may require general anesthesia.
ASA CLASSIFICATION SYSTEM
The American Society of Anesthesiologists (ASA) system estimates anesthesia risk based on patient health status:
Class I: Healthy patients undergoing elective procedures.
Class II: Patients with mild, controlled systemic disease.
Class III: Patients with severe but non-disabling systemic disease.
Class IV: Patients with severe, disabling, life-threatening systemic disease.
Class V: Moribund patients with less than 24-hour life expectancy.
ORAL SEDATION AGENTS (LIGHT SEDATION)
- Narcotics: Meperidine
- Anxiolytics: Hydroxyzine, Promethazine
- Benzodiazepines: Diazepam, Flunitrazepam, Midazolam
- Hypnotics: Chloral hydrate
BENZODIAZEPINES
Benzodiazepines have anxiolytic, sedative, hypnotic, muscle relaxant, amnesic, and anticonvulsant properties. They can be administered orally or parenterally.
Indications:
- Anxiety management
- Pre-anesthetic induction
- Dental procedures
- Hospital use
Diazepam: Long-acting anxiolytic with sedative-hypnotic effects. Widely used in dentistry.
Flunitrazepam: Potent, short-acting hypnotic with sedative effects.
Midazolam: Ultra-short-acting hypnotic causing drowsiness.
Chloral Hydrate: Sedative-hypnotic with variable effects ranging from sedation to sleep.
HYDROXYZINE
Hydroxyzine provides sedation, anxiolytic activity, and antihistamine properties. It can be combined with other CNS depressants or nitrous oxide.
INHALATION SEDATION: NITROUS OXIDE
Nitrous oxide is a non-toxic gas that produces sedation, relaxation, and analgesia.
Advantages:
- Rapid onset and offset
- Easy dose control
- Minimal side effects
Uses:
- Cooperative school-aged children with mild to moderate anxiety
Contraindications:
- Uncooperative children with severe behavior problems
- Toddlers
- Children with nasal obstruction or respiratory problems
Disadvantages:
- Weak agent
- Potential lack of patient acceptance
- Equipment requirements
Administration:
- Start with high oxygen and low nitrous oxide concentration, gradually adjusting as needed.
- Administer local anesthetic once sedation is achieved.
- Provide 100% oxygen for 5 minutes after the procedure.
- Maintain verbal contact with the child to promote relaxation and cooperation.
Midazolam or hydroxyzine can be combined with nitrous oxide for enhanced sedation.
SPECIAL CONSIDERATIONS
Pharmacological behavior management through conscious sedation requires additional training and expertise. Sedation failure can lead to control problems, while excessive sedation can quickly become a life-threatening emergency.
ANTIBIOTICS
PENICILLINS
Penicillin G or Penicillin V: Effective against gram-positive cocci, some gram-negative cocci, and anaerobes. Sensitive to beta-lactamase.
Amoxicillin: Broad-spectrum penicillin effective against a wider range of bacteria, including some gram-negative organisms.
Amoxicillin + Clavulanic Acid: Clavulanic acid inhibits beta-lactamase, making it effective against bacteria resistant to amoxicillin alone.
Cloxacillin: Penicillinase-resistant penicillin effective against staphylococci and streptococci.
MACROLIDES
Erythromycin: Bacteriostatic macrolide antibiotic, an alternative for penicillin-allergic patients.
Clarithromycin: Macrolide derivative with better absorption, distribution, and longer half-life than erythromycin.
Azithromycin: Macrolide derivative with excellent absorption, tissue distribution, and a long half-life, allowing for once-daily dosing.
BACTERIAL ENDOCARDITIS
Infective endocarditis is an inflammation of the heart valves, often caused by bacteremia during dental procedures.
Streptococcus viridans is a common causative organism, along with Staphylococcus aureus, S. epidermidis, and Enterococcus faecalis.
TREATMENTS REQUIRING PROPHYLAXIS
All dental procedures involving gingival or periapical tissue manipulation or perforation of the oral mucosa.
DENTAL PROCEDURES NOT REQUIRING PROPHYLAXIS
- Routine anesthetic injections
- Radiographs
- Removable prosthesis or orthodontic appliance placement/adjustment
- Orthodontic bracket placement
- Tooth extractions
- Bleeding from lip or oral mucosa injuries
PATIENTS REQUIRING PROPHYLAXIS
- History of infective endocarditis
- Congenital heart disease
- Prosthetic heart valve
- Heart transplant recipients with valve regurgitation
PROPHYLAXIS REGIMEN FOR DENTAL PROCEDURES
Amoxicillin: 50 mg/kg 1 hour before the procedure.
Penicillin-allergic patients:
- Clindamycin: 20 mg/kg 1 hour before
- Clarithromycin or Azithromycin: 15 mg/kg 1 hour before