A review on moderate sedation in pediatric dentistry: a focus on indications, safety and the newest medications

Introduction

Dental caries is highly prevalent among children globally and untreated dental decay can lead to hospitalizations, emergency room visits, loss of school days, diminished ability to learn, and an overall decrease in oral health-related quality of life (1-3). One of the most difficult tasks for a dentist treating children with dental caries is behavior management. There are many nonpharmacologic ways a dentist can manage behavior including tell-show-do, positive reinforcement, distraction, memory restructuring, and desensitization (4). These modalities work well a majority of the time but there are situations where a pediatric patient needs additional assistance to complete dental treatment (4). Fearful patients where the nonpharmacologic modalities do not work, patients that are unable to cooperate due to mental, physical or medical conditions, and patients where sedation may protect the developing psyche and reduce medical risk are candidates for sedation (4). Sedation, a drug-induced state, can range from minimal to moderate to deep (5). Minimal sedation, a minimally depressed level of consciousness that retains the patient’s ability to maintain an airway and respond normally to tactile stimulation and verbal command independently and continuously, can be used for various procedures in pediatric dentistry if that child needs more anxiolysis to complete treatment (5,6). For example, if a child is fearful but willing to complete treatment, this may be a good choice to assist the child in completing treatment and reduce the fear. Nitrous oxide is routinely used in most pediatric dental offices and this produces anxiolysis or mild sedation for the child (4). Moderate sedation is the next most common modality that most pediatric dentists complete if a child needs more than just anxiolysis to complete treatment (6). An example would be a child fearful where mild sedation was not successful to complete treatment, or a child who, at recall, the dentist evaluated and felt anxiolysis most likely would not be effective enough to complete treatment. Moderate sedation is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, with or without light tactile stimulation (5). Cardiovascular function is maintained, spontaneous ventilation is adequate, and no interventions should be needed to maintain a patent airway (5). If mild or moderate sedation does not work, deep sedation or general anesthesia may be considered (4) (Table 1).

Since moderate sedation is a useful technique that allows the dental procedure to be completed in the dental office by the pediatric dentist, and not within the hospital, it is more readily available to patients. Modalities such as deep sedation [usually intravenous (IV) sedation] and general anesthesia should have an additional provider or an anesthesiologist to administer the medication, and many times this is then completed in the hospital. Moderate sedation provides an intermediate option to assist children in getting through dental procedures, where the traditional behavioral approaches have failed or will not work, and where deep sedation or general anesthesia are not needed to complete the dental work.

Many children are fearful of the dentist to begin with and Locker et al. found that for adults who had dental fear, half reported this fear started in childhood (7,8). A traumatic dental episode in childhood has been found to have a long-lasting effect into adulthood. It has also been found that there is a relationship between dental fear in a child and the number of extractions a child experiences; therefore, a connection exists between fear and invasive treatment (9). Patients who develop a fear of the dentist are less likely to complete preventive oral care, leading to poor oral health (10). This development of fear can be avoided if the psyche of the patient is considered. If conventional treatment modalities are not working for a child, especially when more invasive dental procedures are required, other tools such as moderate sedation should be considered. This extra tool to have as a pediatric dentist allows children a higher chance of not developing a fear of the dentist, thus maintaning good oral health into adulthood.

Providing moderate sedation as an option is challenging, as there is still a scarcity of evidence to assist clinicians in selecting and administering proper medications safely and effectively (11). Residency programs in pediatric dentistry differ in the drug regimens they teach and particular medications are more challenging to order that were more frequently used in the past. With these challenges, understanding how to make sedation as safe as possible with the incorporation of scales to assess quality and safety can be useful. Also, understanding the newest medication regimens is important, as what was taught in pediatric dental residency programs a few decades ago is different than what is taught currently.

Children frequently present to the clinic with the need to address caries and therefore need restorative treatment that will be difficult for a child to complete conventionally. To complete dental treatment effectively and minimize psychological trauma, moderate sedation is a modality of treatment that can be performed by a qualified and trained dentist. This review gives an overview of current regions with moderate sedation. It highlights safety with the newest scales that should be considered if moderate sedation is being completed to provide quality assessment and increase safety, along with preparation prior to sedation. Additionally, the newest medications currently used are emphasized, as this is an evolving modality in pediatric dentistry. With older medications not being available or harder to obtain, newer and different medications must be considered.

A focus on safety: preparation, proper monitoring, and scales used during pediatric dental sedation

Adequate preparation prior to completing sedation is essential to provide a safe environment. A systematic approach, such as using SOAP-ME, helps so important drugs or equipment needed are not missed. This acronym makes it easier for the provider to prepare and plan. “S” stands for suction catheters, “O” for oxygen, “A” for airway, “P” for pharmacy, “M” for monitors, and “E” for special equipment or drugs (12). If an emergency is encountered, this checklist provides a well prepared environment.

Adequate preparation also involves making sure proper nothing by mouth [Nil Per Os (NPO)] guidelines are followed. Pulmonary aspiration is of concern with sedation if the child regurgitates and is unable to protect their airway. It is not known the exact risk of aspiration during elective procedural sedation but there have been reported incidences ~1 in 825 to ~1 in 30,037 (12-18). It is not well known if moderate sedation itself can lead to aspiration. However, if a deeply sedated child requires intervention for apnea, laryngospasm, or airway obstruction, the rescue maneuvers could increase the risk of pulmonary aspiration (5). The standard practice for intake of food and liquids before elective sedation should follow the same guidelines as those for general anesthesia (12,19). The child may still take routine necessary medications with a sip of clear liquid or water if needed. By following the NPO guidelines, the risk of pulmonary aspiration is minimized.

Proper monitoring before during and after the sedation is also imperative to provide a safe experience for the patient. An appropriately trained individual must always remain in the operatory during treatment to monitor the patient continuously. Oxygenation saturation by pulse oximetry along with capnography [monitoring end-tidal carbon dioxide (CO₂)] to ensure the patient is ventilating and receiving adequate oxygen during the procedure should be completed. Capnography helps detect respiratory problems such as apnea earlier than the pulse oximeter making it now a standard to add for monitoring sedations (12). At times capnography may not be accurate since patient movement affects the monitoring. Deferring the initiation of capnography until the child is sedated may assist in not agitating the patient. Continual observation of breath sounds should be done with a precordial stethoscope for best accuracy (6,12,20). While not all practitioners utilizing moderate sedation use this device, it is a first line of defense against a potential disaster. While providers using general anesthesia have moved more away from precordial stethoscope use, improved technology has made this device more useful now for sedation. Capnography for nonintubated cases can have many issues where the readings are inaccurate. The precordial stethoscope provides a sensitive measure of the quality of the airway (21). This device is available now with improved audio, wireless and going directly to a Bluetooth earpiece, allowing more than one person to listen at a time and a person monitoring can now freely move around compared to the traditional precordial stethoscope where you are limited how far you can be from the patient (21-23). Breath sounds should be recorded at a minimum every ten minutes, but five minutes is encouraged pre-operatively, post-operatively and intraoperatively. Blood pressure and heart rate should be evaluated additionally in the same increments (6). Electrocardiogram (ECG) monitoring is encouraged and required with any patient with a history of cardiovascular disease. Documentation of the sedation should include names of all drugs administered, time administered, route of administration, local anesthetics dosages, and all physiological parameters (6).

Behavior is important to record. One of the most frequently used behavior scales in clinical dentistry and research is the Frankl Scale (Table 2) (4). This scale is used routinely by many dentists to record the patient’s behavior for every appointment. The scale rates the behavior from definitely negative (− −) to definitely positive (+ +). This global score is also helpful to use during sedation as it assists in recording how the patient responded to the sedation and is especially helpful if additional sedations are needed (24-26).

The Pediatric Sedation State Scale (PSSS) is a 6-point scale that measures the quality of procedural sedation or the state of the patient during a procedure (27). This newer to the literature scale has not currently been in the literature for pediatric dental sedation. This scale has been validated and allows a way to measure the effectiveness and efficiency of sedation in more detail. In this scale, there are six sedation states, each assigned a numerical value with higher numbers for increasing activity states. A score of 0 is defined as a sedation associated with abnormal physiological parameters that require acute intervention to 5 which is described as a patient moving (purposefully or non-purposefully) in a manner that impedes the proceduralist and requires forceful immobilization. This includes crying or shouting during the procedure, but vocalization is not required. The score is based on movement. This scale can assist in understanding behavior, but also effectiveness, in pediatric sedation. Another available observational procedural scale that looks at the depth of the sedation is the University of Michigan Sedation Scale (28).^. This scale has been validated in pediatric patients but only for pediatric patients undergoing nonpainful procedural sedation (children undergoing computed tomography). It uses a scale of 0 to 4, with 0 being awake and alert, and 4 being sedated and unable to respond to stimulation. This scale is beneficial as it is simple and a quick assessment that can be easily incorporated into a busy practice.

Proper postoperative care is important to ensure the child is safe for discharge. Once the child begins to awake, it is suggested that vital signs still be recorded, but can be increased to every 10 to 15 minutes (6). Proper discharge criteria must be met. The American Academy of Pediatric Dentistry (AAPD) guidelines provide a sedation sheet with discharge criteria for patients (29). In the procedural sedation record, there is a section that has eight specific criteria along with discharge vital signs to document and assist in proper discharge. The criteria for discharge include cardiovascular function is satisfactory and stable, airway patency is satisfactory and stable, patient is easily arousable, responsiveness is at or very near presedation level, protective relexes are intact, patient can talk (return to presedation level), patient can sit up unaided (return to presedation level), and state of hydration adequate. The discharge vital signs include pulse, oxygen saturation, blood pressure, respiratory rate, and temperature (29). The discharge criteria and vitals provided within the AAPD guidelines are unfortunately, not validated. A major advantage is that the discharge sheet is easily accessible on the AAPD website for any pediatric dentist to use and it provides a simple checkbox to fill in and use. Lastly, a modified Aldrete score can also be used prior to discharging the patient (30). This scale consists of 5 clinically relevant parameters looking at the physiological recovery and includes muscle activity, respiration, circulation, consciousness, and oxygen saturation. There is a score from 0 to 10, with 8 or higher indicating a patient is suitable for discharge. This scale though, has only been validated for after general anesthesia and in an ambulatory surgical setting, not moderate sedation. This scale may also take a little longer to complete than the AAPD guideline checkbox. All scales have their pros and cons currently and obviously, more research needs to be completed in pediatric moderate sedation and validation of scales in pediatric dentistry and sedation. It is still important that a patient is properly discharged and any of these scales enables a safer discharge.

Lastly, it is also important to track adverse events during sedation from a quality improvement perspective. Tracking and Reporting Outcomes Of Procedural Sedation (TROOPS) was developed and allows for easy consistent tracking of adverse events with a checklist to identify sedation outcomes or interventions that warrant quality improvement review (31). TROOPS, while not validated. was developed by the International Committee for the Advancement of Procedural Sedation to provide a quality improvement review of sedations. The main components of the checklist include airway/breathing, circulation, neurological, sedation quality, and patient experience. The checklist is easily accessible on the TROOPS website and can be easily printed and used. There is another checklist of adverse events provided by the Pediatric Sedation Research Consortium (PSRC). This list has tracked adverse events with propofol in pediatric procedural sedation, ketamine in pediatric sedation, for magnetic resonance imaging in pediatrics, and intranasal dexmedetomidine sedation in pediatric medicine, however, it is not validated (15,32-34). The adverse events tracked and noted include agitation/delirium, airway obstruction, allergic reaction, apnea, aspiration, cardiac arrest, coughing, death, desaturation with oxygen saturation less than 90% for more than 30 seconds, emergency anesthesia consultation, emergent airway intervention, hypothermia, inadequate sedation, IV related complication, laryngospasm, secretion excessive enough to require treatment, stridor, unexpected change in heart rate or blood pressure greater than 30% of baseline (notes also as hypotension or bradycardia), unplanned admission to hospital or increased level of care, vomiting, use of reversal agents, and wheezing. Both these scales have the potential to be incorporated within dentistry, to provide a way to track adverse events in sedation, and to better understand and perform safe sedations in the future.

Associated risks of pediatric dental sedation

Pediatric dental sedation can have serious associated risks; therefore, it is necessary to understand procedural, medication, and physiological risks along with risks associated with comorbidities. There have been several cases that have resulted in death or permanent neurologic damage (6,35).

Procedural risks

Procedural-related risks can occur in pediatric sedation and proper monitoring, as described, must be done with every case. Without proper monitoring, a patient can desaturate or become unstable without the dentist’s knowledge. Chicka et al. found with a review of closed malpractice insurance claims, that 46% of cases were recorded as “visual only” or “none”, with 46% where the monitoring not being able to be determined. This only left 8% where proper physiological monitoring was completed (36). Aspiration may also be of concern; pediatric patients are often moving during a sedation making a risk of a crown or item to end up in the airway. This makes isolation essential during a sedation with the use of a rubber dam or an other isolation system (37).

Medication risks

Medication risks may include drug dosing errors or interactions of multiple drugs. Chicka et al. found that in the review of closed malpractice insurance claims local anesthetic overdoses were observed in 41% of claims and ranged from 118% to 356% of the maximum recommended dosage, with 86% of the time a general dentist administering the local anesthetic. There is documentation that sedation with opioids and other central nervous system (CNS) depressants has a synergistic CNS depressing effect, therefore increasing the risk of local anesthetic toxicity (27,38). It is also hypothesized that benzodiazepines may mask the local anesthetic toxicity reaction (36). Local anesthetic maximum dose calculations must be completed prior to the sedation, especially with young children and when more extensive treatment is indicated (6,27,39). Coté et al. found that the use of 3 or more sedating medications compared to 1 or 2 was strongly associated with adverse outcomes (40). Combinations of CNS drugs increase the risk of unexpected oversedation and respiratory depression, and this is more commonly seen with opioids. When using more than one drug, medication dosages should be decreased and the practitioner must have a clear understanding of the effects of combining medications (6).

Comorbidities

Comorbidities may exist for pediatric patients. Patients with an American Society of Anesthesiologists (ASA) status of I or II are considered appropriate candidates for moderate sedation, but children who are ASA class III or IV or who present with anatomic abnormalities should be considered for sedation with caution (12). For example, patients with uncontrolled asthma would be considered ASA III therefore, consultation with subspecialists prior to proceeding should be completed. Patients with tonsillar hypertrophy with a Brodsky score of III and IV (tonsillar tissue is more than 50%) are not good candidates for sedation as the airway is already compromised. Neonates and former preterm infants may have immature hepatic and renal function that alters the ability to metabolize and excrete sedation medications therefore these patients should also have a consultation with appropriate subspecialists prior to proceeding (40,41). Many parents also may not correctly relay accurate medical information to the dentist; therefore, a history and physical from the primary care provider is important to get accurate information on any comorbidities. This should occur within 30 days of the sedation appointment (42).

Physiological risks

Physiological risks with children are different than those of adults. Sedation for pediatric patients poses a higher risk, especially children under the age six years old (6,40). Anatomical airway characteristics, including a larger head, larger tongue, smaller mandible, and more cephalad larynx, put pediatric patients at higher risk for sedation. Young children also have a floppy epiglottis, larger adenoids and tonsils, and smaller cricoid cartilage, all of which can obscure a laryngeal view (43). All these anatomical features can put a pediatric patient more at risk of respiratory failure from hypoventilation or airway obstruction. Proper monitoring and training with pediatrics is essential so an intervention can be completed prior to major adverse events.

Medications used for pediatric dental moderate sedation

Drugs used to produce moderate sedation can include local anesthetics, nitrous oxide, opioids, benzodiazepines, chloral hydrate, barbiturates, antihistamines, and dexmedetomidine. Drugs can be administered through routes such as oral, nasal, intramuscular, IV, subcutaneous, and inhalation (44). Inhalational nitrous oxide is routinely used for pediatric dental procedures. Oral administration is the next most common route utilized in pediatric sedation (45). Intranasal sedation is additionally a more common route in which drugs may be administered and is useful for children unwilling to take oral meds and has a quick onset of action. Administration of all medications is recommended to occur within the dental office or hospital, in a controlled environment, not outside the office (45). Below are the more commonly used medications in moderate sedation for pediatric dentistry currently.

Local anesthetics

Local anesthetics are used to block the nerve cells from sending pain signals to the brain, therefore a temporary loss of sensation in the selected area occurs (46). Local anesthetic agents are also cardiac depressants. They can cause excitation or depression of the CNS. The maximum allowable safe dosage should be calculated prior to administration. If the highest dosage is used, there is concern of enhanced sedative effects, therefore lower dosages should be used during sedation. It is important for the clinician to also aspirate frequently to avoid the local anesthetic going directly into a blood vessel. If emergent treatment for an overdose is indicated, administration of 20% lipid emulsion should be completed (47-49).

Nitrous oxide

Nitrous oxide is one of the main choices for mild sedation during a dental procedure due to safety. It can be used alone or in combination with other sedation medications for moderate sedation. It has properties that induce relaxation and modify noxious stimuli from the dental treatment, where at times local anesthetic is not needed for minor restorative procedures (50). Nitrous oxide has anxiolytic effects by activation of gamma-aminobutyric acid (GABA) receptors through the benzodiazepine binding site (51,52). The anesthetic, amnestic, and analgesic properties occur due to the antagonism of N-methyl-D-aspartate receptors (51). Nitrous oxide is rapidly absorbed through the pulmonary alveoli and the effects are seen within minutes. The excretion of nitrous oxide occurs quickly leading to a rapid recovery (27). In addition to relaxation and modification of noxious stimuli, nitrous oxide can result in symptoms such as tingling of extremities or a feeling of warmth within a few minutes (45). Nitrous oxide can be titrated with an increase in efficacy of a sedation regimen and deepening a sedation (53,54). High levels of nitrous oxide and changing the percentage of nitrous oxide multiple times during a procedure can lead to nausea and vomiting (54,55). Overall, nitrous oxide is utilized frequently and has few adverse events. The most common adverse event is nausea and vomiting and this occurs in only 1.2 to 1.8 percent of patients (56,57).

Benzodiazepines

Benzodiazepine sedation is one of the more common modalities used in pediatric dentistry. Benzodiazepines do not have significant respiratory depressant effects at the correct therapeutic dosage and there is a reversal agent that can reverse the effects in case of an overdose (33). Midazolam is used for procedures that are not long in duration and it has a short onset of action. This medication is used routinely preoperatively for general anesthesia to decrease the anxiety of a child prior to going back into the operating room (58). Pediatric dentists also routinely use it for sedation to complete procedures of shorter length. Significant side effects remain rare with the administration of midazolam in pediatric dentistry (59). In medicine, it has been shown that per os (PO) midazolam is effective at 0.25 mg/kg for premedication for general anesthesia and during diagnostic/treatment procedures (60). This medication can be administered intranasally or orally. The intranasal route is a non-invasive procedure that most children generally tolerate well. The medication is administered by a mucosal atomizer device, which breaks the medication into smaller, more easily absorbed particles increasing rapid absorption (61). Intranasal midazolam helps achieve anxiolysis and amnesia (61,62). Minor adverse effects that have been reported include irritation to the nose and a bitter taste (63). Triazolam is also used in pediatric dentistry but has fewer studies of efficacy in children. It has been classified as a hypnotic and has a longer onset and half-life than midazolam. Typically, this medication is administered to older children, 7 years of age and older, where midazolam is less likely to be effective due to age and weight (64). Diazepam is another benzodiazepine used in pediatric dentistry. It has a longer duration of action caused by its active metabolite, desmethyldiazepam, which is slowly eliminated. It has shown promise as a sedative but is not regularly used for children of a young age.

Opioids

Opioids can decrease a patient’s psychological reaction to painful stimuli, reduce unwanted motor activity and sedate a child (6). Respiratory depression is the biggest concern with the use of this type of medication (65). Patients may additionally have side effects of nausea and vomiting (66). Dosages are usually higher to achieve sedation than what is needed for analgesia (45). Meperidine is one of the more commonly used opioids in pediatric dentistry. It is a synthetic opioid agonist with a more rapid onset of action than morphine. It has an onset of approximately 30 to 60 minutes and is rapidly absorbed from the gastrointestinal tract. Patients taking monoamine oxidase inhibitors or serotonin reuptake inhibitors should not take meperidine due to the risk of serotonin syndrome. It has also been found that meperidine is metabolized to normeperidine, which is a potential neurotoxin and with repeated use has been shown to result in anxiety, hallucinations, tremors, myoclonus, and seizures (67). Many hospitals now limit the use of meperidine due to occurrences of adverse events, drug interactions, and other better drug options (68).

Morphine

Morphine is a mu receptor agonist that has been historically used for analgesia but has also been used as an oral sedation regimen. It does not have the neurotoxic metabolites that are found in meperidine, hence the recent increase in popularity. Respiratory depression is a risk along with nausea, vomiting, itching, excessive somnolence, and dizziness (69). There is little evidence on oral morphine as a singular drug for moderate oral sedation in pediatric dentistry but newer studies have explored its use in combination with other drugs (69,70). Chen et al. looked at combining PO morphine with benzodiazepines (midazolam or diazepam) and hydroxyzine with the idea that this produces a synergetic sedative effect. This study found an 80–81% success rate for completing dental treatment (70). Schneider found that morphine with hydroxyzine encouraged the use of morphine after a 9-year observational study (71).

Barbiturates

Barbiturate medications were used prior to the introduction of benzodiazepines. For pediatric dentistry, the most frequently used agents were secobarbital and pentobarbital (72). Due to the paradoxical excitement and therapeutic dosage range being limited, these medications are no longer used (45).

Combining medications

Drugs in different classes have been combined to have a potentially more sedative effect. A past popular drug combination was chloral hydrate and meperidine, with or without hydroxyzine. Chloral hydrate has developed a reputation for being less predictable therefore decreasing its use. Chloral hydrate has been associated with laryngospasm, cardiac arrhythmias, cardiac arrest, and seizures (73,74). There is no reversal for chloral hydrate, making overdose more likely to result in a fatality. Due to these side effects, fewer people are using this medication and thus this combination.

Meperidine with midazolam is another combination utilized. Midazolam alone has a short working time. Adding meperidine to midazolam has been shown to increase the working time (75). This regimen with higher mg/kg dosages of meperidine necessitated physical arousal to awaken 10–14% of subjects in one study and more studies are needed to have a better understanding of this drug regimen (75).

Hydroxyzine, an antihistamine, is a medication typically used in combination with other sedatives. Hydroxyzine alone or in combination with nitrous oxide was not found to provide better overall behavior, but at the proper dosage, this drug has been found to have synergistic effects with certain drugs such as midazolam (76,77). It is classified as a histamine blocker and has additional sedative, antiemetic, anticonvulsant and anticholinergic properties, making it advantageous to pediatric sedation (71). Its onset of action is usually 15 to 30 minutes (71). A popular combination routinely used in pediatric dentistry is hydroxyzine with midazolam. This combination has shown promising results and studies have found children are more likely to exhibit quiet and/or sleep behavior than midazolam alone (71,76,77). Additionally, midazolam is short-acting and fast-onset with effects of sedation occurring around 20 minutes after oral administration. Hydroxyzine is longer acting, therefore helps extend the sedation to provide more dental treatment and also helps prevent nausea and vomiting during treatment.

A triple drug regimen of benzodiazepine, hydroxyzine and oral morphine sulfate was recently investigated for moderate oral sedation in pediatric dentistry. This combination of morphine with a benzodiazepine provides a synergistic sedative effect, with one study allowing for reducing dosing to get a desired effect (70). Their results demonstrated an 80% success rate, but a chin lift was used to correct minimal airway compromise with cases in this study.

Newer drugs in sedation in pediatric dentistry

Dexmedetomidine is a central alpha-2 adrenergic agonist (63). In some studies, it has been shown to have neuroprotective properties, decreasing apoptosis in humans (78). Dexmedetomidine can produce analgesia, anxiolysis, and sedation that mimics sleep (79-81). One benefit is that it does not interact with opioid and GABA receptors and thus does not cause respiratory depression, commonly caused by other sedative agents. Dexmedetomidine can be administered via a variety of routes, including intranasal, oral, buccal, intramuscular, and IV. It has been used for years in pediatric medicine for pediatric imaging procedures and electroencephalogram studies, showing similar sedative effects of midazolam and less respiratory depression than narcotics (82). Intranasal dexmedetomidine has shown promising results in effectiveness and safety for pediatric dental sedation (81-84). The working time for dental procedures has been found to be longer than medications such as midazolam and the combination of midazolam with hydroxyzine (83). ElKhatib et al. found that dexmedetomidine had an increased ease of treatment completion compared to midazolam (85). Patients who received dexmedetomidine and ketamine buccally compared to dexmedetomidine buccally alone had better behavior in one study. This route of administration though is rarely used routinely in pediatric dentistry (86). There is still limited quality research on dexmedetomidine in moderate sedation in pediatric dentistry but thus far the results are showing promise.

Reversal agents

Naloxone is a competitive opioid antagonist with a high affinity for mu opioid receptors, leading to the reversal of opioids. IV and intraosseous administration provides a fast route of administration with a noticeable reversal within minutes. It can be delivered both intramuscularly and subcutaneously. Recently an intranasal naloxone spray was developed and can be used for case of overdose. The patient will still have to be closely monitored after administration of the reversal, as the duration of action of opioids can exceed the duration of action of naloxone (87).

Flumazenil is an imidazobenzodiazepine. It has a high affinity for the GABA_A receptor, acting as a competitive antagonist to benzodiazepines and nonbenzodiazepines. Flumazenil should not be administered and is contraindicated in patients with a history of seizure and chronic anxiety disorders where benzodiazepines are used (88).

With reversal medications, it is still imperative to provide the necessary proper oxygenation, monitoring, and any needed rescue maneuvers such as a chin lift. Proper emergency protocols in conjunction with reversal administration must be completed to provide the proper safety to the patient.

Conclusions

There are many cases where conventional behavioral treatment modalities for pediatric dental treatment will not work or will not protect the developing psyche of a child. In these cases, pediatric moderate sedation should be considered but should be completed by an individual with the proper experience and training. While many sedation regimens are available, there is also a lack of research to support which medication or combination of medications that are most effective. The medications used for pediatric sedation also vary by practitioner along with their experience and training. Adverse risks can occur with pediatric sedation. Understanding preparation, monitoring, and using as many safe measures as possible will limit the risk associated with moderate sedation in pediatric dentistry. Overall, pediatric dental moderate sedation is useful by a trained dentist for fearful and uncooperative children where conventional behavioral treatment options are not an option.

Acknowledgments

The author would like to thank Dr. John H. Unkel, MD, DDS, MPA, FAAP and Dr. William Piscitelli, DDS, MS for their edits to this manuscript.

Footnote

Peer Review File: Available at https://joma.amegroups.com/article/view/10.21037/joma-24-24/prf

Funding: None.

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://joma.amegroups.com/article/view/10.21037/joma-24-24/coif). The author has no conflicts of interest to declare.

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