2014 Sedation Safety Week

Pediatric Sedation Standard of Care

John P. Bitting, Esq. Regulatory Counsel

Let’s say you’re a GP who has decided to provide access to care to pediatric dental population. Let’s say for the sake of argument they are between the ages of 5 and 12 years old. You remember learning something in dental school – from professors who haven’t touched a patient in 30 years – about chloral hydrate being the sedative of choice for pediatric “patient management.” You read something on, let’s call it, Dentistville,about combining one or two other drugs with your sedative of choice in order to manage those very young or more difficult children.

You read. You heard. You read. You heard.

You receive postcards in the mail. You see magazine ads. You stroll past the AGD or ADA annual meeting booth of a sedation training provider. You ignore all of these.

Then, perhaps in response to your ad or website, a three year old boy and his father present to your office for a crown. You recommend sedation for this procedure. You speak confidently about what you’ve read and heard, but never learned nor practiced, about pediatric sedation.

In the middle of the procedure, the vital signs monitor indicates a steep decrease of the child’s oxygen saturation, he loses consciousness, stops breathing, and turns blue. Do you know what to do? You know CPR, right? So does every dentist in America.

The key to pediatric sedation – or sedation for any age – is knowing who to sedate and not to sedate. This takes special training. Once you learn who is okay to sedate, then you need to learn the science, procedure, and protocols behind safe but effective sedation. This takes special training. Caring for pediatric patients means responding appropriately to the needs of the parents. This takes special training.

There is a caries crisis in the United States, amongst other childhood oral issues. But we don’t have enough pediatric dentists to serve the vastly growing and underserved pediatric dental population. General dentists must step up. But they must NOT step up blindly.

Learn.

Learn to assess. Learn to select. Learn to manage. Learn the procedure. Learn the protocols. Learn to monitor. Learn the equipment. Learn the drugs. Learn the follow-up. Learn to care. They’ll keep coming back.

It’s a shame that only seven states require pediatric-specific training before a dentist – any dentist – can give a kid a little sedativeto calm his or her nerves before sticking a needle in that kid’s mouth.

On the other side of the regulatory spectrum, six states require that dentist to have an intravenous sedation permit before providing even a miniscule amount of oral sedative to pediatric patients. FYI, most if not all of the IV sedation training programs cover adults only, not kids. This is what I refer to as “regulatory overkill.”

DOCS Education’s pediatric faculty recommend the following:

  1. Patients age 5 to 12 years.
  2. ASA I only. Otherwise, refer them to a specialist or, if you have hospital privileges, provide their dentistry there while an anesthesiologist provides the sedation.
  3. DOCS’s pediatric faculty teach a comprehensive 25-hour Pediatric Sedation Dentistry (“PSD”) course that also has a two-way, live-feed live patient experience. It’s really quite state-of-the-art.
  4. Do you know what to do in an emergency?
  5. The PSD course covers airway management and emergencies, but the faculty are all PALS-certified and strongly recommend that dentists providing pediatric sedation get PALS-certified as well.
  6. Have the appropriate monitoring equipment and emergency drugs. The following list is from California, one of those seven states that requires pediatric-specific training for pediatric sedation:

(1)Operatory large enough for patient and a team of three (3) to move around;

(2)Table or dental chair firm enough for CPR;

(3)Adequate lighting including backup;

(4)Suction including backup;

(5)Portable positive pressure 02 delivery system

(6)Inhalation sedation equipment, if used in conjunction with oral sedation;

(7)Emergency equipment:

(a)Oral airways (age-appropriate sizes)

(b)Sphygmomanometer;

(c)Precordial or pretracheal stethoscope;

(d)Vital signs monitor with pulse oximetry

(8)Emergency drugs:

(a)Epinephrine

(b)Bronchodilator (e.g. albuterol inhaler)

(c)Appropriate drug antagonists (e.g. flumazenil)

(d)Antihistamine (e.g. benadryl or hydroxyzine)

(e)Anticholinergic

(f)Anticonvulsant (e.g. Valium®)

(g)Oxygen

(h)Dextrose or other antihypoglycemic (e.g. Glucogel)

(9)Ancillary items, not required in rules, but DOCS and others consider standard of care:

(a)Recordkeeping: health history form, consent forms, companion instructions, anesthesia chart, written emergency protocols appropriate for BLS or PALS

(b)Capnography

(c)AED

This is a small price to pay for doing things the right way.

If you have regulatory questions, feel free to contact me at .