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Pharmacology in Pediatric Dentistry: Pain, Anxiety and Conscious Sedation

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Pharmacology in Pediatric Dentistry

Pain and anxiety control in pediatric dentistry

The vast majority of pediatric dental patients can receive dental treatment with conventional behavior management techniques and pain control. However, in some cases, controlling pain and anxiety requires going beyond conventional techniques. Pharmacological treatment is indicated for children who cannot receive traditional behavior management techniques, local anesthesia and conduction anesthesia.

Conscious Sedation

Definition: A minimally depressed level of consciousness that allows the patient to independently and continuously maintain a patent airway, respond appropriately to physical stimulation and verbal commands.

Levels of conscious sedation

  • Light sedation (oral route)
  • Sedation with nitrous oxide (inhalation route)
  • Deep sedation (rectal, nasal or intramuscular route)
  • General anesthesia

Special considerations: monitoring in the dental office

  • Pulse oximeter
  • Precordial stethoscope
  • Blood pressure cuff

The sedation technique should not prevent the patient from waking up easily and responding intentionally to verbal commands throughout the procedure. This definition corresponds to deep sedation.

If conscious sedation is not properly administered and adequate monitoring is not performed, the patient may present cardiovascular and respiratory depression. A patient who has partial or complete loss of protective reflexes and cannot maintain a patent airway independently may suffer apnea or hypoxemia, which entails a risk of death.

Objectives of conscious sedation

  • Reduce anxiety so the patient feels safe, calm and comfortable enough to undergo dental treatment.
  • Reduce movements and adverse reactions during treatment.
  • Increase patient cooperation.
  • Increase tolerance during long treatments.
  • Help patients who are physically and psychologically compromised to undergo treatment.

Considerations

  1. Prior evaluation of behavior.
  2. State of health and prior assessment of general oral health.
  3. Collaboration, participation and signed informed consent from parents or guardians.
  4. Economic considerations.
  5. Alternatives to treatment.
  6. Training, professional experience and staff expertise.

Indications for conscious sedation

  • Patients with existing pathologies:
    • Psychiatric disorders or patients with severe mental alterations
    • Muscular disorders or patients with severe spastic alterations
  • Patients with dental phobia (adult learners) or children difficult to manage (non-receptive)
  • Prior to surgery
  • Patients with a loss of consciousness (types I and II)

Patients with intolerance to local anesthetics (general anesthesia) and patients with physical disabilities or severe mental retardation (general anesthesia).

ASA classification system

The classification system of the American Society of Anesthesiologists (ASA) is used to estimate the anesthetic risk of the patient:

  • Class I: Healthy patient, no surgical or systemic disease.
  • Class II: Mild systemic disease, controlled and not disabling. May or may not be related to the intervention.
  • Class III: Severe systemic disease, with limitations or disabling.
  • Class IV: Severe and disabling systemic disease, constantly life-threatening, that cannot always be corrected by surgery.
  • Class V: Moribund or dying patient, whose life expectancy is less than 24 hours, with or without surgical treatment.

Drugs administered orally (light sedation)

Narcotics: meperidine

Anxiolytics: hydroxyzine, promethazine

Benzodiazepines: diazepam, flunitrazepam, midazolam

Hypnotics: chloral hydrate, benzodiazepines

These drugs have anxiolytic, sedative, hypnotic, muscle relaxant, amnesic, anticonvulsant and skeletal muscle relaxant activity. Administered orally or parenterally.

Indications: anxiety management, pre-anesthetic induction, dental procedures. For use in a hospital setting.

Diazepam (benzodiazepine anxiolytic with sedative action and hypnotic properties)

  • Its onset of action is long (average half-life greater than 24 hours).
  • Not widely used in dentistry (central nervous system effects).
  • Presentation: diazepam laboratory 5 mg tablets.
  • Dose: 0.1–0.2 mg/kg body weight.

Flunitrazepam (hypnotic benzodiazepine with hypnotic action and sedative properties)

  • About 10 times more potent than diazepam.
  • Intermediate action (10–22 hours).
  • Should be given with caution.
  • Presentation: flunitrazepam laboratory 2 mg.
  • Children: 0.5–1 mg/2 hours.

Midazolam (hypnotic benzodiazepine)

  • Ultra-short action (1–2 hours), lasting 30–60 minutes of effective action.
  • Causes drowsiness.
  • Dose for children: 0.5–0.7 mg/kg (30 minutes before the procedure).
  • Maximum total dose: 15 mg.
  • Presentation: 15 mg tablets (adults), 7.5 mg tablets (children).
  • Other names: midazolam, nocturnal.

Chloral hydrate (sedative hypnotic)

  • Oral administration. Its depressant effects may vary the sedation level depending on the time of administration.
  • It is not found in the national pharmaceutical market. It can be requested by prescription (compounding pharmacy) using the following formula:
    • Chloral hydrate 20 g
    • Distilled water 100 ml
  • Hypnotic dose in children: 30–50 mg/kg body weight.
  • Effects appear within 15–30 minutes and reach maximum activity after one hour.

For use in a hospital setting.

Hydroxyzine

  • Produces sedation and anxiolytic activity and has antihistaminic effects.
  • Oral administration.
  • Effects appear within 30 minutes; activity reaches its maximum at 1–2 hours.
  • Can be used in combination with central nervous system depressant drugs (meperidine, chloral hydrate) or nitrous oxide.
  • Antiemetic properties.
  • Dose: 25 mg, one hour before the appointment.
  • Presentation: 20 mg tablets, syrup 10 mg/5 ml.

Sedation by inhalation: nitrous oxide

A non-irritating, non-toxic gas that produces sedation, relaxation and analgesia.

Advantages:

  • Rapid blood levels (low solubility in plasma).
  • If administration is interrupted, blood levels decrease rapidly.
  • Easy to control dosage (not more than 50% of the pediatric patient's dose).
  • Absence of serious side effects.

Indications:

  • Acceptable for children of school age who need more than a simple cleaning.
  • Children with anxiety and/or considerable distress who can collaborate with treatment.

Contraindications:

  • Children with serious behavioral problems who do not cooperate with the use of the mask.
  • Very young children.
  • Children with nasal obstruction or respiratory problems.

Disadvantages:

  • Weak agent.
  • Lack of patient acceptance.
  • Inconvenience.
  • Potentiation (combination with other sedatives).
  • Equipment requirements.

Administration

  • Titration: Start with the maximum concentration of oxygen and minimum nitrous oxide, then adjust according to the degree of sedation reached, increasing gradually.
  • Once sedation is achieved, anesthesia is administered locally.
  • After completing the procedure, 100% oxygen is given for 5 minutes.
  • Verbal contact with the child is maintained to encourage relaxation and reinforce cooperative behavior.

Nitrous oxide can be combined with midazolam or hydroxyzine, plus nitrous oxide.

Special considerations

Alternative methods of pharmacological behavior control for conscious sedation in children represent a very complex and demanding task requiring additional training and specialization.

The child may remain sedated for an undefined period. If a child receives an excessive dose of sedation, the situation can rapidly become an emergency in the dental office.

Antibiotic Therapy

Penicillin G / benzylpenicillin

  • Increased activity against gram-positive and gram-negative microorganisms, and anaerobic cocci that produce penicillinase. Little activity against gram-negative bacilli.
  • Parenteral administration.
  • Dose for children: 100,000 IU/kg body weight/day.
  • Drawbacks: acid labile, sensitive to beta-lactamases.

Phenoxymethylpenicillin (penicillin V)

  • Spectrum similar to penicillin G, but sensitive to beta-lactamases.
  • Oral administration (stable to gastric pH, administered away from meals).
  • Relatively low availability (every 6 hours).
  • Dose for children: 25–50 mg/kg body weight/day in 4 doses.

Amoxicillin

Broad spectrum (including gram-positive and gram-negative flora). Greater capacity than penicillin against gram-negative bacteria. Gastrointestinal absorption 80 to 90%. Can be administered with meals. Indicated for infections of the skin and soft tissues produced by streptococci, penicillinase-non-producing staphylococci, Escherichia coli and Proteus mirabilis.

  • Dose for children: 50 mg/kg body weight/day every 8 hours (up to 20 kg).
  • Over 20 kg: 250–500 mg every 8 hours.
  • Commercial presentations: amoxicillin oral suspension 5 ml/250 mg (laboratories: Amobiotic, Amoval, Abiolx, Aminopexil).

Amoxicillin + clavulanate

Clavulanic acid inhibits the beta-lactamases produced by bacteria that destroy amoxicillin. It is indicated mainly in infections of the skin and soft tissues and, in particular, with cellulitis and dental abscesses. Cellulitis that spreads rapidly is commonly produced by Staphylococcus aureus, Streptococcus pyogenes and Bacteroides spp. Some strains produce beta-lactamases, rendering them insensitive to amoxicillin alone.

  • Dose for children: 50 mg/kg/day every 8 hours.
  • Commercial presentations: amoxicillin + clavulanate oral suspension 5 ml/250 mg–62.5 mg (laboratories: Ambil, Clavinx, Augmentin).
  • Amox: 5 ml/400 mg, Ambil 57 mg, twice daily; 5 ml every 12 hours.

Cloxacillin

  • Belongs to the penicillin group known as "antistaphylococcal" and is used to treat infections caused by staphylococci that produce beta-lactamases. It is active against staphylococci and sensitive microorganisms resistant to penicillin, Streptococcus pyogenes and Streptococcus pneumoniae. However, penicillin G is more active against penicillin-sensitive bacteria, Enterococcus faecalis and gram-negative microorganisms.
  • Oral or parenteral administration.
  • Dose for children: 50 mg/kg body weight/day every 8 hours.
  • Commercial presentations: flucloxacillin oral suspension 125 mg/5 ml or 250 mg/5 ml (laboratories: Xil, Andromaco, Vitalpn/Labomd).

Erythromycin

  • Bacteriostatic macrolide antibiotic.
  • Oral or parenteral administration.
  • Good absorption orally (best taken with an empty stomach).
  • Alternative for patients allergic to penicillin.
  • Dose for children: 50 mg/kg/day every 8 hours.
  • Commercial presentations: erythromycin oral suspension 5 ml/200–400 mg (laboratories: Andromaco, Pasteur, Xil, Mercina/Mpro).

Clarithromycin

A derivative of erythromycin with the following advantages:

  • Greater gastrointestinal absorption.
  • Greater distribution.
  • Longer half-life (administered every 12 hours).
  • Alternative for patients allergic to penicillin.

Dose for children: 7.5 mg/kg body weight every 12 hours.

Commercial presentations: Pro-clar (Xil), Euromicina (Saval) suspension 5 ml/125–250 mg, Clarimax (Andromaco).

Azithromycin

A derivative of erythromycin with the following advantages:

  • Greater absorption than other macrolides.
  • Greater volume of distribution, high concentrations in tissues.
  • Prolonged half-life, administered every 24 hours.
  • Better gastrointestinal tolerance.

Dose for children: 10 mg/kg on day 1, then 5 mg/kg daily for 4 days.

Commercial presentations: Azitrom (Xil) suspension 5 ml/200 mg, Abactn (Andromaco), Trx (Saval).

Bacterial Endocarditis

Infective endocarditis is an inflammation of the inner lining of the heart chambers and heart valves (endocardium).

Endocarditis usually results from bacteremia (the presence of bacteria in the blood), which can occur during certain dental procedures, among others.

Bacteria circulating in the bloodstream can settle on damaged heart valves and multiply, forming bacterial vegetations or growths. These clots can break off and travel to the brain, lungs, kidneys or spleen.

People who develop infective endocarditis usually have an underlying heart disease. Streptococcus viridans is responsible for almost half of all bacterial endocarditis cases. Other common agents are Staphylococcus aureus, S. epidermidis and E. faecalis.

Prophylaxis treatments

Dental manipulations involving gingival tissue, the periapical region or perforation of the oral mucosa require prophylaxis.

Dental procedures for which prophylaxis is not recommended:

  • Routine anesthetic injections through non-infected tissue.
  • Taking dental X-rays.
  • Placement of removable prostheses or orthodontic appliances.
  • Adjustment of orthodontic appliances.
  • Placement of orthodontic brackets.
  • Loss of deciduous teeth.
  • Bleeding from injury to the lips or oral mucosa.

Indications for prophylaxis:

  • Patients with a history of endocarditis.
  • Congenital heart disease.
  • Prosthetic heart valve.
  • Heart transplant recipients with heart valve disease.

Regimen for dental procedures:

Therapeutic scheme: amoxicillin, children: 50 mg/kg, 1 hour before the appointment.

For patients allergic to penicillin: clindamycin 20 mg/kg body weight, 1 hour before; or clarithromycin or azithromycin 15 mg/kg body weight, 1 hour before.

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