International Journal of Applied Dental Sciences 2022; 8(2): 176-180

ISSN Print: 2394-7489

ISSN Online: 2394-7497
IJADS 2022; 8(2): 176-180 Sedation in pediatric dentistry, an overview and
© 2022 IJADS
www.oraljournal.com
current update
Received: 20-10-2021
Accepted: 23-12-2021
Mariana Garza Garza, Rosa Isela Sanchez Najera, Enrique Nieto
Mariana Garza Garza Ramírez, Maria Teresa Perez Quintero, Sonia Lilia Aguilar Dominguez,
Master of Sciences Student,
Universidad Autonoma de Nuevo Edith Lopez Ramirez, Montserrat Ruiz Paz and Juan Manuel Solis Soto
Leon, Facultad de Odontologia,
Monterrey, Nuevo Leon, 64460 ZIP,
Mexico DOI: https://doi.org/10.22271/oral.2022.v8.i2c.1507

Rosa Isela Sanchez Najera Abstract

Professor, Universidad Autonoma de
Introduction: Conscious sedation is a technique of administering sedatives or dissociative agents with or
Nuevo Leon, Facultad de
Odontologia, Monterrey, Nuevo Leon, without analgesics to induce a state that allows the patient to tolerate unpleasant procedures.
64460 ZIP, Mexico Objective: To analyze the literature on the types of sedation and the different drugs that can be used such
as midazolam, dexmedetomidine, propofol, and nitrous oxide.
Enrique Nieto Ramírez Methodology: A comprehensive search was performed in PubMed, SCOPUS and Google Scholar using
Professor, Universidad Autonoma de
Nuevo Leon, Facultad de keywords such as sedation, pediatric dentistry, midazolam, dexmedetomidine, propofol, nitrous oxide.
Odontologia, Monterrey, Nuevo Leon, Results: The types of sedation are minimal, moderate, and general anesthesia, these are important in
64460 ZIP, Mexico order to provide the best option according to the patient's age, condition and level of anxiety. Oral
midazolam is usually used as a premedication causing good behavior, patient cooperation and decreased
Maria Teresa Perez Quintero
Professor, Universidad Autonoma de
anxiety. Dexmedetomidine has anxiolytic, analgesic effects and little postoperative agitation. Propofol
Nuevo Leon, Facultad de has a fast effect, short duration and fast elimination helping dentists to carry out dental treatments; as
Odontologia, Monterrey, Nuevo Leon, well as nitrous oxide, these two are preferred by parents.
64460 ZIP, Mexico Conclusion: The best drug for sedation in pediatric dentistry is nitrous oxide because it is preferred by
parents for being safe, effective, with minimal side effects and gives a good working time, it can be used
Sonia Lilia Aguilar Dominguez
Professor, Benemerita Universidad in patients with special needs, with excessive anxiety or behavioral disorders making it a good alternative
Autonoma de Puebla, Facultad de for sedation.
Estomatologia, Puebla, Puebla, 72410
ZIP, Mexico Keywords: Sedation, pediatric dentistry, propofol, nitrous oxide, midazolam, dexmedetomidine
Edith Lopez Ramirez
Professor, Benemerita Universidad 1. Introduction
Autonoma de Puebla, Facultad de
Estomatologia, Puebla, Puebla, 72410
Pediatric dentists have always faced the difficult task of managing dental fear and anxiety,
ZIP, Mexico which is an obstacle to successful treatment of children and even impedes the quality of care
by the dentist [1].
Montserrat Ruiz Paz
Professor, Universidad Autonoma de Patients with particular medical conditions and extensive dental complications tend to show
Nuevo Leon, Facultad de greater fear and lack of cooperation in their treatment, mainly due to physical problems,
Odontologia, Monterrey, Nuevo Leon, mental disabilities, or behavioral management problems [2]. Nowadays, there are different
64460 ZIP, Mexico
techniques used to manage them, among which sedation with different anesthetic agents has
Juan Manuel Solis Soto become popular [3].
Professor, Universidad Autonoma de
Nuevo Leon, Facultad de
Conscious sedation is a technique of administering sedatives or dissociative agents with or
Odontologia, Monterrey, Nuevo Leon, without analgesics that induce a state that allows the patient to tolerate unpleasant procedures
64460 ZIP, Mexico while maintaining cardiorespiratory function. This achieves a depressed level of consciousness
that allows the patient to maintain oxygenation and airway control independently [4]. It is
considered the most used technique for children with dental anxiety [5], as consciousness is
minimally depressed, but the ability to maintain an open airway, protective reflexes and a
response to verbal and physical stimulation is maintained [6].
Corresponding Author:
Mariana Garza Garza
Sedation can be performed by different methods, either orally, through parenteral route with
Master of Sciences Student, benzodiazepines, inhaled with nitrous oxide, or intravenously [7]. The most used anesthetic
Universidad Autonoma de Nuevo agents, administered individually or in combination, are diazepam, midazolam, propofol,
Leon, Facultad de Odontologia,
Monterrey, Nuevo Leon, 64460 ZIP,
ketamine, opiate agonists such as fentanyl or remifentanil, and dexmedetomidine; and on the
Mexico other hand, the most used inhalation agents are nitrous oxide and sevoflurane [8].
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In pediatric dental practice we encounter multiple the GI tract and enters directly into the systemic circulation;
complications that reduce the success rate of treatment. within this, administration via the inhaled route has become
Therefore, conscious sedation is considered an effective increasingly popular in pediatric dentistry [9].
technique, since it reduces patient anxiety, can be used in It is important to know the types of sedation (minimal,
patients with disabilities, avoids abrupt movements, dental moderate, deep, and general anesthesia) used in pediatric
treatment is carried out in a short period of time, and is safe. dentistry so that professionals in this area can offer the best
The aim of this research is to analyze the literature on the option according to the age of the patient and the level of
types of sedation used and the different medications that can anxiety they present, as well as knowing the type of sedation
be used for conscious sedation in pediatric dentistry, such as suitable for patients with special conditions, since sometimes
midazolam, dexmedetomidine, propofol and nitrous oxide. airway and/or cardiovascular assistance is required.

2. Materials and Methods 3.2 Midazolam

Articles on the subject published through the PubMed, It is one of the benzodiazepines used for perioperative
SCOPUS and Google Scholar databases were analyzed, with conscious sedation [17]. Midazolam can be administered orally,
emphasis on the last 5 years. The quality of the articles was intranasally and through parenteral route, but has an
evaluated using guidelines, i.e., identification, review, choice unpredictable response, it can be safely used as an oral
and inclusion. The quality of the reviews was assessed using premedication for intravenous (IV) sedation of pediatric
the measurement tool for evaluating systematic reviews. The dental patients [18,19]. Oral administration of midazolam in
search was performed using Boolean logical operators AND, doses of 0.5 mg per 1 kg body weight of the child is safe [20],
OR and NOT. The search was performed using Boolean as it does not produce any respiratory depression in children,
logical operators AND, OR and NOT; with the keywords: decreases the need for analgesics, increases the recovery rate
"sedation", “conscious sedation”, "pediatric dentistry", in children undergoing general anesthesia for dental treatment
"midazolam”, “dexmedetomidine”, “propofol” and “nitrous [21]
and makes patients more cooperative [22]. One of the
oxide”. The keywords were used individually, as well as each advantages of midazolam is that it can be combined with
of them related to each other. other drugs such as ketamine, which provides moderate dental
sedation when administered intranasally, and presents minor
3. Results and Discussion adverse events, with marked variability in the behavior of
3.1 Types of sedation children during dental treatment [23]. The combination of
Drugs must provide sedative, analgesic, and amnesic midazolam and chloral hydrate also shows improved
properties, as well as a rapid onset of action and a short cooperation for dental treatment in children [24].
duration to allow safe and rapid recovery [4]. Midazolam is often used as a sedative preoperative
There are different types of sedation, established by the medication in pediatric dentistry, with benefits of good
guidelines of the American Academy of Pediatric Dentistry behavior, patient cooperation and decreased anxiety.
(AAPD), the American Academy of Pediatrics (AAP), and the
American Dental Association (ADA) [9]. 3.3 Dexmedetomidine
Minimal sedation, i.e., the lowest depth of sedation can be Dexmedetomidine (DEX) is a highly selective α-2 agonist
easily obtained using oral sedatives, requires no special that produces sedative, anxiolytic and analgesic effects
equipment or tools, and does not affect ventilatory and without causing respiratory depression and with a low
cardiovascular function [10]. This type of sedation is also incidence of postoperative agitation [25]; it is an effective and
called anxiolysis and the patient is awake and relaxed and safe drug and that is why it is gaining importance in pediatric
able to respond normally to verbal stimuli [11]. sedation. This drug can be administered orally, intravenously,
Moderate sedation is drug-induced, during which patients intranasally and intramuscularly [26]. Oral DEX is often used
respond with determination to verbal commands, no as a premedication, provides satisfactory levels of sedation,
interventions are required to maintain a patent airway, ease of separation from parents and mask acceptance in
spontaneous ventilation is adequate and cardiovascular children [27]. In addition, it decreases unexpected patient
function is usually maintained [12]. movements during dental surgery compared to sedation with
Deep sedation is a drug-induced depression of consciousness Propofol and Midazolam [28]. It can be combined with other
during which, patients cannot be easily awakened, as there is oral medications such as Ketamine and Fentanyl, serving as
a loss of protective reflexes; however, they respond an alternative in pediatric sedation, as the combination of
purposefully after repeated verbal or painful stimulation. dexmedetomidine and oral fentanyl also promises to be a
Cardiovascular function is maintained, but it is necessary to potential sedative agent for children with respect to their
keep the airway patent [13,14]. successful anxiolysis during treatment procedures [29]. It has
General anesthesia (GA) involves a drug-induced loss of been reported that this intravenous drug can be combined with
consciousness during which patients cannot be awakened, a low dose of Midazolam, being useful for dental treatment of
even by painful stimulation. The ability to maintain an uncooperative pediatric patient requiring minimal
ventilatory function independently is often impaired as its treatment [30]. Intranasal DEX also has satisfactory and
cardiovascular function [15]. This type of analgesia is used effective premedication regimens for uncooperative children
[31]
because of the extensive and complex treatment requirements . The intravenous moderate sedation regimen with DEX
and insufficient cooperation often related to the patient's age has been shown to produce a milder sedation event. This
[16]
. method of anesthesia may be effective in reducing the waiting
In the oral route agents administered that are absorbed time for GA treatment as well as the morbidity associated
through the gastrointestinal (GI) tract or oral mucosa are with GA [32].
referred to as enteral sedation, and are subject to enterohepatic This drug has been shown to be a good choice as a sedative in
circulation and first-pass effect before the drug is released pediatric dentistry due to its anxiolytic and analgesic effects
into the systemic circulation. The parenteral route bypasses and low postoperative agitation. One of the advantages of this
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sedative is the reduction of unexpected movements of the pediatric dentistry and preferred by parents. It is a safe
patient during treatment and its combination with other drugs. sedative that provides good working time and has the
advantage of being administered to patients with mental
3.4 Propofol retardation, excessive anxiety, and behavioral disorders.
Propofol is an intravenous anesthetic used for sedation during
monitored anesthetic care or as an induction agent for general 4. Conclusions
anesthesia [33]. It has a short duration of action, rapid From a practical point of view, the best drug for conscious
elimination and dose-dependent effects leading to changes in sedation in pediatric dentistry is nitrous oxide. Nitrous oxide
blood pressure and heart rate at higher doses [34]. It allows is generally preferred by the parents of patients because it is
dental procedures in uncooperative pediatric patients to be safe, effective, and has minimal side effects, in addition, it
performed safely and effectively in an outpatient setting by provides a good working time, and can be used in patients
qualified personnel in the management of any complications with special needs, excessive anxiety or behavioral disorders,
[2]
. This anesthetic can be combined with Midazolam, offering making it a good alternative for pediatric conscious sedation.
acceptable side effects as an advantage. Lin et al, reported
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