Sophia, a three-year-old pretty girl has been complaining of toothache. It comes and goes and her mom gives her a pain reliever each time, and would pray the pain just goes away. Until one day, Sophia cries hysterically because of the pain, unable to eat and wakes up in the middle of the night, crying in pain. It was only during this time that Sophia's mom looks around for a dentist that will take Sophia. And Sophia's mom is shocked when the dentist tells her the many cavities on her child's teeth, and she is need of tooth extractions and crowns. Is that even possible for a three-year-old? Worse, she is told that they will have to sedate her child because of the complicated treatment. This shocks her even more. Sophia's mom is stressed and afraid of the procedure. Such is a common scenario among our patients.
According to the most recent National Oral Health Survey in 2018, 86% male and 84% female five-year-old Filipino children have tooth decay. And this is a major public health problem globally and the most widespread non-communicable disease. Tooth decay, if left untreated can lead to devastating effects. Since tooth decay is a bacterial infection, this can spread throughout our body, which may cause dentoalveolar infections like cellulitis and severe infections like meningitis, brain abscess and infective endocarditis.
And so, Sophia needs treatment … and quickly. She's unable to eat, sleep nor go to school because of the pain. She has lost weight and is very irritable. The possibility of a systemic infection is highly likely, as Sophia's immune system becomes compromised due to decreased food intake and sleep. Proceeding with treatment means sedation. Sophia's mom knows her daughter won't be able to withstand a local anesthesia injection, moreso a dental extraction. Her child would be traumatized for life! Since she cannot keep still, her safety will be compromised as the chances of aspiration of the tooth fragments and accidental cuts from the sharp dental instruments becomes probable. But the question is … Is sedation safe?
Sedation involves taking in drugs into the system to put an anxious patient in a calm and relaxed state. The patient is half-awake and her reflexes remain intact. Depending on the drugs used, it can produce an amnesic effect, thereby eliminating any traumatic memory of painful drilling and tooth pulling.
However, the US Food and Drug Administration in 2017 issued a warning that repeated or prolonged use of general anesthetic and sedation drugs during surgeries in children younger than three years old or in pregnant women during their third trimester may affect a child's brain development. But it worthy to note that these findings were consistent with animal studies and recent human studies have suggested that a single, brief exposure to general anesthesia and sedation drugs in infants or toddlers is unlikely to affect their behavior or learning.
Sedation can be mild, moderate or deep and the respiratory system becomes more depressed, the deeper a sedation is. Since sedation is a continuum, a patient in a state of moderate sedation can slip into deep sedation without warning. The risk for sedation cannot be overemphasized — and this is why the training of the dentist and her team is very important. It is not always possible to predict how a patient will respond but what's important is the whole team recognizes this and should be able to act on it. The dentist should be trained to recognize the patient is in distress and rescue the patient accordingly.
The Philippine Pediatric Dental Society, Inc. released clinical practice guidelines on "Non-Hospital Amubulatory Sedation for Dental Procedures in Children"1 in 2021. The guidelines are meant to promote safe and quality dental service for all children who will undergo sedation. It covers the type of children who are to be sedated; the qualifications of the dentist and the dental team (anesthesiologist and dental aides) who will perform the treatment — the dentist should have undergone formal training in sedation as he/she should be well-versed with the pharmacology of the drugs to be used; and the whole dental team should be able to act on adverse events in a quick and skillful manner during the course of the treatment; and the minimum equipment and facilities should be present in the dental clinic.
Since Sophia is a well-child, with no significant medical issues and is assessed to have a good airway, then she is deemed to be a good candidate for sedation. A risk stratification or a medical clearance from the pediatrician is requested prior the procedure. While sedation has its risks, the benefits of doing the procedure outweigh the risks specifically for Sophia's case. What's important is Sophia's mom should be able to find a dentist who will be able to prevent and manage those risks. A successful procedure means there will be unremarkable recovery after the procedure and it will eliminate pain and the source of infection which will make her eat, sleep and go back to school. It will make her healthier as she'll be able to eat and sleep better; she'll be able to focus on her studies more and Sophia will have an overall better quality of life.
Since Sophia's mom is considering to have dental treatment for Sophia under sedation, the Philippine Pediatric Dental Society suggests the following:
- Look for a qualified pediatric dentist. Not all training programs of pediatric dentistry cover sedation and it's important the dentist has the appropriate training.
- Talk about the treatment plan with your pediatric dentist. Is there an alternative treatment plan to avoid sedation?
Saving the baby teeth, while ideal is not the only goal. The goal is for a child to be free from pain and infection. While teeth will certainly help a child's nutrition and are important for the child's emotional and mental well-being, modifying the ideal treatment plan for a faster procedure even if under sedation, is justifiable for the best interest of the child. Discuss this with your pediatric dentist. - An anesthesiologist is imperative for moderate sedation procedure. Ask about the anesthesiologist's training, too. While anesthesiologists are medical doctors who underwent additional training, dental sedation has its peculiarities as the dentist and anesthesiologist both work on a shared airway. There are anesthesiologists who are not adept in working with dental procedures.
- Assess the dental aides. Do they seem like they know what they are doing? Efficiency is key for faster and quality procedures.
- A hospital-based practice is better than a solo dental practice. There are more hands to help out in case an emergency arises.
- Look around the dental clinic. Is the facility equipped to handle emergencies? While this may be hard to assess — the presence of wide hallways, an emergency stretcher, an elevator, emergency kits and an oxygen tank should all be conspicuously displayed for easy access during an emergency.
But remember, tooth decay is preventable. Invasive dental treatment, sedation, severe pain and infection are all avoidable if only we can keep our children's teeth healthy and clean. Brushing our children's teeth with fluoride toothpaste twice a day, avoiding nighttime bottle feeding, choosing snacks with less sugar, limiting snacking to twice a day, drinking lots of water and establishing a dental home by age one will all help to prevent tooth decay and keep our children healthy.
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1Philippine Pediatric Dental Society, Inc. (2021) PPDSI Clinical Practice Guidelines on Non-Hospital Ambulatory Sedation for Dental Procedures in Children. https://ppdsi.org.ph/ppdsi/clinical-practice-guidelines