Children of all ages may need dental care for a wide range of symptoms from pain during eruption of teeth, dental caries and infections to application of braces for misaligned teeth and complex repair of the facial bones in children with special needs.
Dental procedures in children mandate a calm quiet child with an open mouth to ensure safe and pain-free conduct of the procedure. However, such treatments are often associated with increased anxiety and fear in children which are important barriers in accepting and tolerating treatment resulting in uncooperative behaviour and further delays.1 The inherent nature of these procedures which require the child to remain still with an open wide mouth and tolerate noise from the dental drill, accept probing of the oral cavity with an array of instruments and comply with numbing injections are often difficult to navigate childhood experiences. Therefore, one needs to understand the causes for fear and anxiety and formulate an effective strategy to ensure optimal treatment in children.
As children grow and develop, their understanding of the disease, medical interventions and hospital experiences continue to evolve with their emotional, cognitive and behavioural states. Although, pain pathways are intact from 20th week of intrauterine life and continue to mature and differentiate with age, a 2-year-old child would not be able to differentiate pain from pressure. On the other hand, school going children can understand concepts, think abstractly and cooperate with treatment when prior information is provided about the procedure. Thus, one needs to be aware of the various behavioural strategies, sedation modalities, general and local anesthetic techniques that could be safely employed in children to provide quality care during dental procedures.1
Common operating room dental procedures include tooth extractions and restorations for dental caries, application of sealants, surgical application of orthodontic brackets on impacted teeth, and dental cleaning to maintain optimal dental health.2
We briefly describe the various psychological and pharmacological interventions that can be tried in children of varying age groups to ensure smooth conduct of sedation and anesthesia in children undergoing dental procedures.
Supporting the child undergoing dental procedure
Two key dimensions to optimal dental care in children include ensuring a healthy oral cavity which often requires operative interventions and ensuring that the children is capable of and willing to continue to utilize the dental services as required.2 As parents and children journey through the dental experience, it is crucial that the anesthesiologist diligently assess the child to determine the level of sedation ideal for the dental procedure. The anesthesiologist needs to communicate clearly and provide the relevant information regarding the diagnosis, procedure to the child and parent and obtain consent for the same.
Suitability for sedation should be assessed by reprising through the child’s medical record for existing or past medical or surgical conditions. Previous history of sedation and anesthesia, allergies and medication history with current physical status assessment including child’s weight and airway needs to documented prior.
If there is a concern for difficult airway or breathing problem and, if dental treatment is needed in infants, neonates or children with ASA grade >3, a trained pediatric anesthesiologist should be involved. There should be facilities for immediate access to resuscitation and monitoring equipment in the dental suite.
The final sedation details should consider the target level of sedation depending upon the procedure, specific contraindications, side effects and or patient/parent preference for the procedure.3 Fasting guidelines should be clearly defined for the procedure and the last food and fluid intake noted in the patient chart. However, if the depth of sedation required is more than moderate with inability to maintain verbal contact, then the 2-4-6 fasting rule* needs to be applied. Regular monitoring under sedation/ surgery includes recordings of heart rate, blood pressure, respiration, oxygen saturation, end tidal carbon dioxide along with pain and coping scores during the procedure.
One of the objectives of sedation in pediatric dentistry include dual goals of reduction and prevention of fear and anxiety associated with procedures and ensuring cooperation for the procedure from the child.4
Research has proven that children who are exposed to noxious stimuli during their childhood are at a risk of developing of significant negative avoidant attitudes towards healthcare. They are prone to develop behavioural problems like posttraumatic stress disorder, chronic pain, etc. Thus, the emphasis on multidisciplinary management taking into consideration emotional, cognitive, psychological and pharmacological techniques to allay pain and anxiety in children during dental procedures is warranted.5
Psychological preparation involves providing information about the procedure, the various sensations to be expected by the child and how to cope during the procedure.
The various non pharmacological techniques that can be employed include:
a) Tell-show-do Technique- In this behavioral technique based on the developmental age of the child, the anesthesiologist in a non-threatening setting, verbally tells about the what, why and how of the procedure followed by demonstration of the procedure utilizing visual, olfactory, auditory and tactile cues and finally completing the procedure if feasible. (Fig. 1 a & b)
b) Voice control technique where in the anesthesiologist can modulate their voice by changing pitch, volume or tone and pace to direct patient behavior.
c) Positive reinforcement techniques involve provision of rewards for required behavior in the form of toys, tokens, verbal praise and positive facial/voice expression.
d) Pre-surgery tour of the hospital departments and the operating room setting, or a virtual tour reduces the stress for the first time or anxious patient and the parents. (Fig. 2)
To facilitate intravenous cannulation before procedures, topical application of local anaesthetic creams such as EMLA over the preferred IV site should be encouraged. The “needle” placement is anxiety provoking for many children. (Figs. 3a,b & c)
Paracetamol (acetaminophen in North America) and ibuprofen can be administered 1 hour prior to procedure as oral premedication agents for pain relief. Flavoured oral Midazolam in the dose of 0.5 mg/kg is often the sedative of choice in young children, although this is not yet available in Canada. Dexmedetomidine administered intranasally at a dose of 2ug/kg has also been used safely as a sedative in older and difficult children undergoing dental procedures.6
a) Parental Presence at Induction:
Children react to hospitalization and separation from parents for dental procedures in varied ways. Infants less than six months of age are often not upset by separation. Older infants and young children (six months to five years) are significantly upset by separation from their parents at the time of surgery and this requires careful planning to ensure separation anxiety is reduced. School age children are less upset by separation and more concerned with the surgical procedure and they often have the wildest misconception of what their surgery involves, of waking up during the surgery and about pain after the surgery. Induction of anesthesia for dental procedure is a stressful event for both child and parents. Occasionally, due to various logistic issues like delay in schedules, postponement of the operating list, forgetfulness, administration of premedication (26%) could be delayed.2 In such a case, either of the parent can volunteer to stay with the child during induction inside the dental/operating suite by wearing a special sterile attire.7, 8
Parents of handicapped or disabled children can be of great assistance to the anesthesiologist at the time of induction. Explanation and good communications with the parents and the child often reduce the pre procedure anxiety to a great extent. However, if parents continue to remain anxious, their anxiety can be transferred to the child’s anxiety level and it is best advised for such parents not to accompany the child to the dental suite. It is wise to explain to the parents prior how their child will respond during induction of anesthesia, by body movements such as up rolling of eyes, movements of the arms and legs and turning of the head. They should be assured that these are normal responses seen during induction. Once the child is induced/ slept the parents can be escorted back to the waiting room. (Figs. 4 a & b)
b) Mask Anesthesia and Intravenous Cannulation:
Inside the operating room the child can either lie on the table or sit on the parent’s lap at the discretion of the parents and anesthesiologist. While doing so, a mask with an inhalation agent is gently applied to the child’s face. Sevoflurane is widely used as an induction agent of choice due to its rapidity of onset and fewer complications. Other properties which favour its use include, lower blood9,10 gas solubility with faster induction and recovery times, negligible pungency, minimal respiratory irritation, stable maintenance of anesthesia with less hemodynamic variation.
Inhalational anesthesia is considered the backbone of pediatric anesthesia and is often used to induce anesthesia due to ubiquitous occurrence of needle anxiety in children of all age groups. The option of having a clear sweet smelling plastic mask close to the face is a readily acceptable option when compared to needles.
Nitrous oxide is used with sevoflurane and oxygen due to its well established centrally acting analgesic and sedative effect as well as its second gas effect.11 Timing for intravenous cannulation following induction depends on anesthesiologist judgement after the loss of eye lid reflex. Based on the evidence from previous literature it is recommended to wait for an optimal time of two to four minutes for attempting intravenous cannulation after the loss of eyelash reflex with sevoflurane and oxygen along with or without nitrous oxide, EMLA cream and premedication.12-14
c) Nasotracheal Intubation:
Nasotracheal intubation is the passage of hollow tube through nostrils, pharynx and into trachea to provide oxygen and ventilation throughout the duration of dental procedures. Most pediatric dentists prefer nasotracheal intubation15 for airway management, because it does not interfere with treatment to move the tube from side to side, it decreases the likelihood of tube displacement from head movement during treatment and evaluation of the dental occlusion can easily be completed. Occasionally nasotracheal intubation are associated with nose bleed, adenoid dislodgement, eustachian tube obstruction, maxillary sinusitis, and bacteraemia.16 Passage of a nasal endotracheal tube by expert Anesthesiologist only very occasionally produces nasal bleeding. Several methods have been described to reduce the incidence of nasal bleeding, including selection of the more patent nostril, use of lubricating gel, use of a smaller tracheal tube (TT), warming of the TT17 and telescoping the TT into catheters.18 Also, intranasal pre-treatment with topical vasoconstrictors like xylometazoline provides significant reduction in the incidence of nose bleed.19,20 Alternatively, anesthesia can also be provided with orotracheal intubation21 or laryngeal mask airway (LMA)22 based on mutual discussion between pediatric dentist and anesthesiologist. Following tracheal intubation, dentist inserts a throat pack into the oral cavity to prevent the blood seeping into the trachea and oesophagus. Anesthesiologists manages the children for the entire duration of procedure with titrated doses of anesthetic gases, muscle relaxants and opioids if needed according to the stages of surgical and hemodynamic response. (Figs. 5a, b & c)
After completion of the procedure and removal of the throat pack, suction should be applied to the oropharynx under direct vision. Residual neuromuscular block should be appropriately reversed, the anaesthetic agent discontinued and 100% oxygen administered. The patient should then be placed in the left lateral position. The tracheal tube or LMA should be removed with the patient breathing spontaneously either awake or deeply anaesthetized.
a) Pain Management:
Intraoperatively great care is taken to ensure the child remains pain free during and after the procedure as well. The treating dentist will often perform a dental nerve block intraoperatively with local anesthetic which significantly reduces the requirement of oral analgesics. Tylenol or NSAIDs can then be given according to body weight to take care of pain after the surgery are usually sufficient. However, IV opioids can be reserved for complex patients or after multiple dental procedures.
b) Postoperative Nausea and Vomiting (PONV):
PONV is rare following dental procedures. Most common risk factors for PONV after dental procedures are children older than 5.5 years of age, Postoperative pain and differently abled children.23,24 In cases involving high-risk groups prophylactic antiemetics can be given intraoperatively or in recovery room if needed.
c) Emergence Delirium (ED):
Sevoflurane is generally the preferred anesthetic agent for induction and maintenance of general anesthesia in pediatric dental procedure. However, it has been recognized that one of the major complications after sevoflurane anesthesia in pediatric patients is emergence delirium (ED) when awakening from general anesthesia, with the reported incidence ranging between 10% and 80%.25 Delirium is characterized by presence of restless, thrashing, inconsolable behaviour, failure to establish eye contact, and a lack of awareness of their surroundings. The delirium is usually transient, dissipating within 10 to 15min without sequalae. Sometimes ED in children is considered as a mysterious complication which increases the risk of patient self-harm, places a burden on nursing staff, and reduces parent satisfaction with the treatment during recovery from general anesthesia.26 Propofol, halothane, alpha‐2 agonists (dexmedetomidine, clonidine), opioids (e.g. fentanyl) and ketamine reduce the risk of ED following sevoflurane anaesthesia. Parental presence even before the child awakes in the post anesthetic care unit decreases the incidence and intensity of ED.7,27
Dental procedures under general anesthesia are psychologically and emotionally stressful for both children and their parents; thus, it is the role of the surgical team and the attending anesthesiologist to explore all the possible ways to ease this experience. Adequate preoperative assessment is required in order to determine the most appropriate method of management, with consideration of the child’s cognitive development and the proposed dental procedure. Given parent preferences and high levels of pediatric dental disease, it is likely that we will see the need for dental procedures continue to grow in the future. This is an exciting opportunity to increase dental procedure success by refining behavioural selection parameters, utilizing modern drugs and routes, and employing the services of an anesthesiologist in outpatient settings.
*“2-4-6 fasting rule” meaning a minimum 2-hour-long fasting for clear fluids, 4-hour-long fasting for breast milk and 6-hour-long fasting for solid foods
- Adewale L. Anaesthesia for paediatric dentistry. Continuing Education in Anaesthesia Critical Care & Pain. 2012;12(6):288 – 94.
- Ashley P, Anand P, Andersson K. Best clinical practice guidance for conscious sedation of children undergoing dental treatment: an EAPD policy document. Eur Arch Paediatr Dent. 2021;22(6):989-1002.
- National Clinical Guideline C. National Institute for Health and Clinical Excellence: Guidance. Sedation in Children and Young People: Sedation for Diagnostic and Therapeutic Procedures in Children and Young People. London: Royal College of Physicians (UK) Copyright © 2010, National Clinical Guideline Centre.; 2010.
- Coté CJ, Wilson S. Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures. Pediatr Dent. 2019;41(4):259-60.
- Nelson TM, Xu Z. Pediatric dental sedation: challenges and opportunities. Clin Cosmet Investig Dent. 2015;7:97-106.
- Jun JH, Kim KN, Kim JY, Song SM. The effects of intranasal dexmedetomidine premedication in children: a systematic review and meta-analysis. Can J Anaesth. 2017;64(9):947-61.
- Gil Mayo D, Sanabria Carretero P, Gajate Martin L, Alonso Calderón J, Hernández Oliveros F, Gomez Rojo M. Parental Presence during Induction of Anesthesia Improves Compliance of the Child and Reduces Emergence Delirium. Eur J Pediatr Surg. 2022;32(4):346-51.
- Shih MC, Elvis PR, Nguyen SA, Brennan E, Clemmens CS. Parental Presence at Induction of Anesthesia to Reduce Anxiety-A Systematic Research and Meta-Analysis. J Perianesth Nurs. 2022.
- Kangralkar G, Jamale PB. Sevoflurane versus halothane for induction of anesthesia in pediatric and adult patients. Med Gas Res. 2021;11(2):53-7.
- Epstein RH, Mendel HG, Guarnieri KM, Staudt SR, Lessin JB, Marr AT. Sevoflurane versus halothane for general anesthesia in pediatric patients: a comparative study of vital signs, induction, and emergence. J Clin Anesth. 1995;7(3):237-44.
- Vetter TR. A comparison of EMLA cream versus nitrous oxide for pediatric venous cannulation. J Clin Anesth. 1995;7(6):486-90.
- Joshi A, Lee S, Pawar D. An optimum time for intravenous cannulation after induction with sevoflurane in children. Paediatr Anaesth. 2012;22(5):445-8.
- Kumar KR, Sinha R, Chandiran R, Pandey RK, Darlong V, Chandralekha. Evaluation of optimum time for intravenous cannulation after sevoflurane induction of anesthesia in different pediatric age groups. J Anaesthesiol Clin Pharmacol. 2017;33(3):371-4.
- Hasan AK, Sivasankar R, Nair SG, Hasan WU, Latif Z. Optimum time for intravenous cannulation after induction with sevoflurane, oxygen, and nitrous oxide in children without any premedication. Paediatr Anaesth. 2018;28(2):179-83.
- Campbell RL, Shetty NS, Shetty KS, Pope HL, Campbell JR. Pediatric Dental Surgery Under General Anesthesia: Uncooperative Children. Anesth Prog. 2018;65(4):225-30.
- Yamamoto T, Flenner M, Schindler E. Complications associated with nasotracheal intubation and proposal of simple countermeasure. Anaesthesiol Intensive Ther. 2019;51(1):72-3.
- Takasugi Y, Futagawa K, Umeda T, Kazuhara K, Morishita S. Thermophysical Properties of Thermosoftening Nasotracheal Tubes. Anesth Prog. 2018;65(2):100-5.
- Watt S, Pickhardt D, Lerman J, Armstrong J, Creighton PR, Feldman L. Telescoping tracheal tubes into catheters minimizes epistaxis during nasotracheal intubation in children. Anesthesiology. 2007;106(2):238-42.
- Song J. A comparison of the effects of epinephrine and xylometazoline in decreasing nasal bleeding during nasotracheal intubation. J Dent Anesth Pain Med. 2017;17(4):281-7.
- El-Seify ZA, Khattab AM, Shaaban AA, Metwalli OS, Hassan HE, Ajjoub LF. Xylometazoline pretreatment reduces nasotracheal intubation-related epistaxis in paediatric dental surgery. Br J Anaesth. 2010;105(4):501-5.
- Bowman JP, Nedley MP, Jenkins KA, Fahncke CR. Pilot Study Comparing Nasal vs Oral Intubation for Dental Surgery by Physicians, Nurse Anesthetists, and Trainees. Anesth Prog. 2018;65(2):89-93.
- Zhao N, Deng F, Yu C. Anesthesia for pediatric day-case dental surgery: a study comparing the classic laryngeal mask airway with nasal trachea intubation. J Craniofac Surg. 2014;25(3):e245-8.
- Kocaturk O, Keles S, Omurlu IK. Risk factors for postoperative nausea and vomiting in pediatric patients undergoing ambulatory dental treatment. Niger J Clin Pract. 2018;21(5):597-602.
- Yumura J, Nakata E, Miyata M, Ichinohe T, Kaneko Y. Risk factors for nausea and vomiting after day care general anesthesia in mentally challenged patients undergoing dental treatment. Bull Tokyo Dent Coll. 2011;52(2):113-8.
- Kawai M, Kurata S, Sanuki T, Mishima G, Kiriishi K, Watanabe T, et al. The effect of midazolam administration for the prevention of emergence agitation in pediatric patients with extreme fear and non-cooperation undergoing dental treatment under sevoflurane anesthesia, a double-blind, randomized study. Drug Des Devel Ther. 2019;13:1729-37.
- Keles S, Kocaturk O. Postoperative discomfort and emergence delirium in children undergoing dental rehabilitation under general anesthesia: comparison of nasal tracheal intubation and laryngeal mask airway. J Pain Res. 2018;11:103-10.
- In W, Kim YM, Kim HS, Hong S, Suh Y, Cha Y, et al. The Effect of a Parental Visitation Program on Emergence Delirium Among Postoperative Children in the PACU. J Perianesth Nurs. 2019;34(1):108-16.
About the Authors
Yuvaraj Kotteeswaran is a Staff Anesthesiologist and Interventional Pain Physician in the Department of Anesthesia at Thunder Bay Regional Health Sciences Centre. He specializes in Regional Anesthesia, Transitional Pain and Chronic Pain Management.
Dr. Ganigara is an Associate Professor and Pediatric Pain Physician in the Department of Pediatric Anesthesia at Indira Gandhi Institute of Child Health, Bengaluru. She is an Executive Member of the Asian Society of the Pediatric Anesthesiology, Pediatric Pain Education Subgroup.
Bruce R Pynn is Oral Health’s editorial board member for oral and maxillofacial surgery. He is an Assistant Professor, North Ontario School of Medicine, Lakehead University, and Chief of Dentistry, Thunder Bay Regional Health Sciences Center.