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Milnes & Farquhar: Options for applying medication
In the final column of our series on issues surrounding the sedation of children in the dentist’s chair, there are other various forms of sedation which can be extremely beneficial to anxious or uncooperative children in need of dental care.
Medications can be taken by children via a number of different routes.
Nitrous oxide and oxygen are inhaled. Other sedative medications we commonly use can also be taken by mouth and swallowed or they can be injected intravenously (IV) into a blood vessel.
Health care providers who administer medications to children know that the most predictable effect from a medication occurs after it is injected into a blood vessel intravenously.
However, children requiring sedation for dental treatment are usually not happy about receiving an intravenous injection to receive their sedative medicines.
The alternative is to give the sedative medication orally.
On the surface, this seems like an excellent solution. But, there are a number of drawbacks to this route of administration.
First, some children are unable or unwilling to take oral medication.
Second, once the medication is in the stomach it is absorbed and transported to the liver where it is undergoes metabolic breakdown.
In many cases, after this initial or first-pass metabolism, only a small amount of active medication remains to exert its sedative effect.
As a result, the effects of orally administered sedatives are highly unpredictable.
Third, each patient receives the exact same dose for their weight because the dosage for oral administration is determined by a patient’s weight.
But we know that not all patients will react in exactly the same way to the same drug because of differences between individuals.
Decades of research on sedative drugs and our own professional experience have shown that oral sedation has a high failure rate because of these various issues we have described.
By far the safest, most predictable and most successful sedative route is intravenous.
Using nitrous oxide and oxygen sedation as well as topical local anesthetic creams on the skin, we are able to address the discomfort a child may feel when an IV is placed.
Breakdown in the GI tract is avoided because the medication is injected into the blood stream for transport to the brain where the sedative exerts it effect.
Unlike with oral sedation, it is possible to administer small amounts of the sedative agent over a period of time until the desired sedation level is achieved.
Thus, the level of sedation can be very carefully controlled whereas with oral administration of sedation, this is not possible.
Another advantage of IV sedation is that very short acting drugs can be given whereas these drugs cannot be given orally because of the longer time between oral administration, uptake from the GI tract, distribution to the brain and finally the onset of the sedative effect.
One final advantage of intravenous sedation which is not available with any other route of drug administration is direct access to the circulation for administration of emergency medications in the unlikely event of an adverse event.
Giving sedative medications to help a child cope with dental treatment sounds easy.
It is, however, a skill which requires advanced training and education and not all dentists are qualified to use sedation.
When a dental office recommends sedation for a child, parents should feel comfortable asking the dentist how they are qualified to do so.
Parents also should know that dental offices using sedation must follow practice guidelines for the sedation of children.
Guidelines for sedation have been developed by medical and dental experts and are promoted by the Canadian Academy of Pediatric Dentistry, the Canadian Dental Association and the College of Dental Surgeons of British Columbia.
The guidelines discuss in detail the steps which a dental team must follow prior to an appointment, during an appointment and after an appointment when a patient has received sedation for dental treatment.
Sedation guidelines have been developed for the safety of all patients who receive sedation for dental treatment.
In our pediatric dental office, all forms of sedation—inhalation, oral and intravenous—are available.
Our team has the education, training and experience to provide sedation safely for any child who will have difficulty receiving dental treatment.
Alan Milnes and Terry Farquhar are certified specialists in pediatric dentistry at 101-180 Cooper Rd.