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Behaviour Management in
Pediatric Dentistry
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Pharmacological Management
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Children’s Behavior
Descriptions of Behavior
Cooperative Behavior: reasonably relaxed, may be enthusiastic, can be treated with
behavior-shaping approach.

Potentially Cooperative Behavior: Has capability to behave well. May be disruptive,

shy, or withdrawn. needs special attention, may need sedation

Lacking cooperative ability (pre-cooperative): very young child with whom

communication cannot yet be established

Uncooperative: most common: pre-schoolers. Tantrum,-tears, loud crying, physical

lashing out. Time-out helps. Restraint/ sedation may be needed

Wright GZ, Kupietzky A, editors. Behavior management in dentistry for children. Wiley Blackwell; 2014
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Differences between children and adults

Children are anatomically and physiologically different from adults. This results in them

becoming hypoxic more easily.

Reasons:
● Anatomy (large head, tongues, tonsils, and adenoids, U-shaped larynx and a narrow
pharynx)
● Higher metabolic rate, and higher oxygen consumption.
● Common upper respiratory tract infections
● Cardiac output in children is 30–50% higher, and the arterial blood pressure is lower,
Smaller veins
● Emotionally and psychologically underdeveloped
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Pharmacological Management
Conscious Sedation: Medical Status (ASA)

Dental I Normal, healthy patient.

clinic
based
II Mild Systemic Disease.

Severe systemic disease. Some functional limitation,

III controlled disease
Hospital
IV Severe systemic disease (constant threat to life)
based

A moribund patient, not expected to survive > 24 hours

V
without surgery, imminent risk of death

American Dental Association. Guidelines for the Use of Sedation and General Anesthesia by Dentists. 2016.
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Choice of pharmacological management

Most suitable pharmacological technique should be based on all the following factors:

• Invasiveness of the proposed procedure

• Level of sedation anticipated

• Contraindications

• Side effects

• Patient (or parent/carer) preference

• Operator preference.
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Pharmacological Management
Conscious Sedation

Oral Inhalation IV Transmucosal

“Conscious sedation is a technique in which the use of a drug or drugs produces a
state of depression of the central nervous system (CNS) enabling treatment to be
carried out, but verbal contact with the patient is maintained throughout the period
of sedation

Wright GZ, Kupietzky A, editors. Behavior management in dentistry for children. Wiley Blackwell; 2014
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Qualities of a sedative agent

Both sedative and analgesic effects
The
Easy and acceptable method of administration
ideal Easy titration
qualities Minimal cardiovascular side effects
of a Minimal respiratory side effects
sedative Rapid onset of action
agent Rapid recovery
are: No accumulation in renal/hepatic dysfunction
Inactive metabolites
Inexpensive
No interactions with other drugs.
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Nitrous oxide inhalation sedation

● Most widely used technique for the paediatric dental patient and can be
used in primary care settings
● It involves the inhalation of an oxygen–nitrous oxide gas mixture in
relatively low concentrations, usually 20–50% nitrous oxide
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Pharmacological Management
Conscious Sedation: Nitrous Oxide
Indications

● Mildly anxious children

● Psychological or physical deficit
● Medically compromised patients
● Needle phobia
● Excessive gag reflex
● As an alternative to GA
● Difficult to anesthetize

Welbury R, Duggal MS, Hosey MT, editors. Paediatric dentistry. Oxford university press; 2018
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Pharmacological Management
Conscious Sedation: Nitrous Oxide
Contra indications
Relative:
• Nasal obstruction
(blocked nose/influenza)
• Wheezing episode
• Mouth breathing
• inability to co-operate
• Motion Sickness

Wright GZ, Kupietzky A, editors. Behavior management in dentistry for children. Wiley Blackwell; 2014
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Pharmacological Management
Conscious Sedation: Nitrous Oxide
Contra indications

Absolute:
• Inability to breathe with
mouth open
• Systemic diseases *
• Nasal or facial deformity
• Severe psychological
disorders

*Myasthenia Gravis, Multiple Sclerosis or Chronic Obstructive airway disease, sickle cell anemia
Wright GZ, Kupietzky A, editors. Behavior management in dentistry for children. Wiley Blackwell; 2014
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Pharmacological Management
Conscious Sedation: Nitrous Oxide (Technique)
1. Consent,
Safety checks, nasal mask size, scavenging pipe is connected
2. 100% Oxygen is set on the mixture (4-6 L/min)
3. Mask is positioned, child is told a hypnotic ‘story’
4. The flow rate is adjusted to match tidal volume of the child
5. Reassurance+ instruction for nasal breathing

6. Mixture dial: O2: 90% (10% N2O) 1 min, O2:80% (20% N2O) 1 min
(caution over this level)
Recovery: 100% O2 for 2 mins+ remain seated for 10 mins

Welbury R, Duggal MS, Hosey MT, editors. Paediatric dentistry. Oxford university press; 2018
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Pharmacological Management
Conscious Sedation: Signs of adequate sedation

Facial tension Blinking frequency Slow responses Laughing/giggling

Glazed eyes Relaxed feet Tingling of fingers Visual changes
and toes
Auditory Feeling Feeling Floating or
changes of of temperature change melting
lightness sensations
Engagement with
Dissociation Day dreaming Change of mood hypnotic
suggestions

Welbury R, Duggal MS, Hosey MT, editors. Paediatric dentistry. Oxford university press; 2018
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IV sedation

IV sedation usually involves the use of midazolam, a benzodiazepine. It intervenes in

the mechanism of gamma-aminobutyric acid (GABA), a transmitter substance in the
CNS. Midazolam has a variety of effects: it is an anticonvulsant, a muscle relaxant, and
an anxiolytic, and has amnesic and sedative–hypnotic qualities. Therefore patients are
unlikely to remember the treatment.
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Pharmacological Management
Conscious Sedation (Other Routes)
Drug Indications Contra-Indications Adv Disadv
I/V - ASA I or II Relative: Hepatic/renal Titratable, Needle phobia,
Midazola - Above 12 years impairment, high BP, rapid onset, respiratory
m - Treatment too no escort, drug use. amnesia, depression,
lengthy for GA Absolute: Allergy, reversal longrecovery,
psychiatric illness (flumazenil)

Oral - ASA I or II Allergy+ same as above Needle-less Non titrable,

Midazola - Under 30 kg used as
m (0.3 to - Short Procedures alternative
0.7mg/kg)

Welbury R, Duggal MS, Hosey MT, editors. Paediatric dentistry. Oxford university press; 2018
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I/V sedation steps

● Topical skin anesthetics (EMLA® 5% (lidocaine 2.5% w/w (25 mg/g), prilocaine 2.5% w/w (25
mg/g)) cream)
● Preoperative checks and child’s blood pressure is taken and noted.
● An ampule of midazolam 5mg dose in a 5 mL concentration
● Attach the pulse-oximeter clip to the patient’s finger.
● Give 1mL (1mg) of midazolam from the syringe over 30 seconds
● Wait for 90 seconds and observe the effect.
● Give increments of 0.5mL (0.5mg) midazolam at 30-second intervals until adequate sedation is
achieved.
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Monitoring of sedative child

● Clinical monitoring—alertness, verbal contact, skin color, response to stimulus,

ability to keep mouth open, ability both to swallow and to maintain an
independent airway, normal radial pulse
● Use of a pulse oximeter (except for nitrous oxide inhalation sedation)
● Blood pressure recordings for IV sedation
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Management of unexpected loss of consciousness

● Cease the operative procedure immediately.

● Ensure that the mouth is cleared of all fluids by using high-volume suction.
● Turn the patient on to his/her side in the ‘recovery position’.
● Consider the administration of 100% oxygen.
● If IV sedation is being used, leave the Venflon (cannula) in place so that emergency
drugs can be administered through it if required.
● Consider monitoring pulse, blood pressure, and respiration. Be ready to start
resuscitation.
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Management of unexpected loss of consciousness

● The dentist should stay with the patient until full signs of being awake are present (eyes
open, independent maintenance of the airways, and verbal contact).
● Follow up the patient by review within 3 days.
● Document and report the incident fully.
● Inform the patient’s general medical practitioner about the incident.
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Pharmacological Management
General Anesthesia
Indications

- Psychological/ emotional immaturity

- Mental, physical, or medical disability
- Extremely uncooperative, fearful, anxious, uncommunicative,
language barrier.
- Significant surgical procedures required
- To protect psyche or reduce medical risk.
- If immediate, comprehensive oral/dental care is needed
Welbury R, Duggal MS, Hosey MT, editors. Paediatric dentistry. Oxford university press; 2018
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Pharmacological Management
General Anesthesia
Contraindications

- Healthy, cooperative patient ,minimal dental needs.

- LA ineffective due to acute infection, anatomic
variations, or allergy
- Medical conditions (malignant hyperthermia, unstable
cardiac condition, poorly controlled cystic fibrosis).

Welbury R, Duggal MS, Hosey MT, editors. Paediatric dentistry. Oxford university press; 2018
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Types of GA for pediatric dentistry

Short GA ( 15 minutes or less)

● Indicated for simple extractions

Long or extended GA (45 minutes or longer)

● Surgical procedures such as the removal of buried and/or malpositioned teeth or the
surgical exposure and bonding of an orthodontic bracket
● conservation and extraction of multiple teeth.
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References
- Welbury R, Duggal MS, Hosey MT, editors. Pediatrics dentistry. Oxford university press; 2018
- Wright GZ, Kupietzky A, editors. Behavior management in dentistry for children. Wiley Blackwell; 2014
- Fux N, Shmueli A, Halperson E, Ram D, Moskovitz M. “Knee-To-Knee” Position for Minor Procedures in
Infants and Toddlers-Dentists Attitudes. J Clin Pediat Dent. 2019;43(2):86-90.
- Jain A, Suprabha BS, Shenoy R, Rao A. Association of temperament with dental anxiety and behaviour of the
preschool child during the initial dental visit. Eur J Oral Sci. 2019;127(2):147-55.
- Attri JP, Sharan R, Makkar V, Gupta KK, Khetarpal R, Kataria AP. Conscious sedation: Emerging trends in
pediatric dentistry. Anesth Essays Res. 2017;11(2):277.
- Hazara R. Conscious Sedation in Dentistry: Selecting the Right Patient. Dent Update. 2020 2;47(4):353-9
- American Academy of Pediatric Dentistry. Use of nitrous oxide for pediatric dental patients. Pediatr Dent
2018;40 (6):281-6
- American Academy of Pediatric Dentistry. Policy on minimizing occupational health hazards associated with
nitrous oxide. Pediatr Dent 2018;40(6):104-5.
- Coté CJ, Wilson S. Guidelines for monitoring and management of pediatric patients before, during, and after
sedation for diagnostic and therapeutic procedures. Pediatr Dent. 2019;41(4):26-52.
- American Academy of Pediatric Dentistry. Periodicity of examination, preventive dental services,
anticipatory guidance/counseling, and oral treatment for infants, children, and adolescents. AAPD
Reference Manual, Vol. 40; 2018.
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Thank you!