I will highlight three topics that, if properly attended to, I believe can dramatically increase the overall safety and effectiveness of procedural sedation and/or general anesthesia associated with children in the office-based dental setting: 1) case selection tools for use in identifying patients eligible to receive sedations, 2) choosing the appropriate type of sedation, and 3) recognition and management of complications associated with sedation. CASE SELECTION TOOLS Patient selection is the most important step in minimizing the risk of sedation for children. Pediatric dentists need to use all assessment tools available to develop criteria which will allow them to choose the proper treatment location, type of sedation to be used, appropriate medications, and route of administration. The major tools available to ensure proper patient selection include: 1) a thorough review of the child’s medical history, 2) a review of systems, 3) a focused physical exam, 4) ASA risk classification, and 5) airway evaluation.
Medical History:
The purpose of a medical history is to gather as much information about your patient as possible. One complicating factor in obtaining an accurate medical history is due to the current trend of parents not being forthcoming when reporting their child’s past or present health history and related medical problems. This reluctance of parents to disclose health problems may be due to issues relating to insurance exclusions or fear of a potential increase in premiums. Because of these factors, it is important, especially when your assessment warrants it, to request a recent history and physical—along with any test or lab results— from the patient’s pediatrician.
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Review of Systems:
This next tool presents a list of questions, arranged by organ system, designed to uncover any existing dysfunction or disease. The review gives a pediatric dentist an opportunity to discover any subjective symptoms that parents either forgot to describe or considered relatively unimportant at the time they filled out the medical history form. In summary, this review serves as a tool enabling a dentist to reveal omissions, inconsistencies, or patient comorbidities not previously mentioned.
Focused Physical Exam:
This exam is used to build on the information gathered during the medical history and review of systems. The first step in a proper physical exam is to obtain the child’s base-line vital signs such as heart rate, respiratory rate, blood pressure and temperature along with the knowledge of the normal values associated with patients of that specific age. The next step is to auscultate the child’s heart and lungs with a quality stethoscope in order to rule out dysrhythmias, murmurs, congenital heart defects, stridor, croup, congestion, or decreased breath sounds. Remember, you don’t need to be a cardiologist, but you do need to know normal sounds from abnormal sounds. I recommend that you execute a YouTube.com search for “heart and lung sounds.” The most common reasons to cancel a child’s scheduled sedation procedure include the following: an undiagnosed heart murmur or murmur greater than a grade II/VI, an upper respiratory infection (URI), cough, cold, flu and/or fever within two weeks of the scheduled procedure. Remember to ask specific questions. This history is critical in avoiding intra-operative airway complications.
ASA Risk Classification:
This tool provides a means of assessing the child’s overall physical health or "sickness" prior to sedation. It is also a predictor of whether or not the child should be treated in an office-based setting. My personal opinion is that only ASA I & II patients should be sedated in an office-based setting.