Best clinical practice guidance for conscious sedation of children undergoing dental treatment: an EAPD policy document

Abstract

Background Due to fear and/or behaviour management problems, some children are unable to cooperate for dental treatment using local anaesthesia and psychological support alone. Sedation is required for these patients in order for dentists to be able to deliver high quality, pain-free dental care. The aim of this guideline is to evaluate the efficacy and relative efficacy of conscious sedation agents and dosages for behaviour management in paediatric dentistry and to provide guidance as to which sedative agents should be used. Methods These guidelines were developed using a multi-step approach adapted from that outlined by the National Institute for Clinical Excellence (NICE (2020) Developing NICE Guidelines: the manual. https://www.nice.org.uk/process/pmg20/chapter/introduction#main-stages-of-guideline-development. Accessed 7 Oct 2020). Evidence for this guideline was provided from a pre-existing Cochrane review (Ashley et al. Cochrane Database Syst Rev 12:CD003877, 2018) supplemented by an updated search and data extraction up to May 2020. Results Studies were from 18 different countries and had recruited 4131 participants overall with an average of 70 participants per study. Ages ranged from 0 to 16 years with an average age of 5.6 years across all included studies. A wide variety of drugs or combinations of drugs (n = 38) were used and delivered orally, intranasally, intravenously, rectally, intramuscularly, submucosally, transmucosally or by inhalation sedation. Twenty-four different outcome measures for behaviour were used. The wide range of drug combinations and outcome measures used greatly complicated description and analysis of the data. Conclusion Oral midazolam is recommended for conscious dental sedation. Midazolam delivered via other methods or nitrous oxide/oxygen sedation could be considered, but the evidence for both was very low.

A Comprehensive Evaluation Between Dexmedetomidine and Midazolam for Intraoperative Sedation in the Elderly: Protocol for a Systematic Review and Meta-analysis of Randomized Controlled Trials

“…Quantitative calculation of heterogeneity is evaluated using I 2 statistics. I 2 statistics are considered to represent the heterogeneity of no (0%), low (0%-25%), medium (25%-75%) and high (75%-100%) possibility [19]. The random effects model would be adopted if medium or high heterogeneity existed between the studies.…”

Use of Midazolam in Paediatric Dentistry

“…Mezi vedlejšími účinky midazolamu byly popsány diplopie, škytavka, ztráta koordinace, halucinace, nauzea a paradoxní reakce [12], v literatuře nazývaná i "angry child syndrom", která je dána nevyzrálostí receptorů hlavně u dětí do třetího roku věku. Jejími typickými projevy jsou agitovanost, excitace dítěte a jeho agresivita vůči okolí a rodičům a její prevalence je 2 % [13].…”

“…Poločas rozpadu flumazenilu je 30 minut, což je kratší doba než poločas rozpadu midazolamu, proto je třeba při výskytu paradoxní reakce podat flumazenil opakovaně a zvážit prodloužení observace dítěte po sedaci. Rutinní aplikace flumazenilu po skončení ošetření pro rychlejší rehabilitaci dítěte není doporučována [1,12].…”

Ambulatory Sedation for Dental Procedures—Case of Cuenca, Ecuador

“…In pediatric dentistry, minimal pharmacological or non-pharmacological interventions are often not sufficient to achieve adequate comprehensive care, since factors such as the extensive treatment needs of the child, acute situational anxiety, age, limited cognitive functioning, long intervention times, physical disability, or medical conditions require deep sedation or general anesthesia to develop dental treatment safely [ 4 , 5 , 6 , 7 , 8 ]. In relation to adults, children have constantly changing anatomical, pharmacokinetic, and psychological differences; therefore, sedation aims to maintain safety, eliminate pain, reduce anxiety, and control behavior, allowing the planned intervention to be carried out [ 9 , 10 ].…”