Recently published guidelines on the use of conscious sedation in dentistry have published varying recommendations on the lower age limit for the use of intravenous conscious sedation. There are a large number of dentists currently providing dental treatment for paediatric patients under intravenous conscious sedation. The 18 cases reported here (age range 11-15 years), were successfully managed with intravenous conscious sedation. The experience in this paper is not sufficient evidence to recommend the wholesale use of intravenous conscious sedation in patients who are under 16 years. The fact that a range of operators can use these techniques on paediatric patients would suggest that further study should be carried out in this population. The guidance should be modified to say there is insufficient evidence to support the use of intravenous conscious sedation in children, rather than arbitrarily selecting a cut off point at age 16 years

J A Leitch

JG Meechan

M -T Hosey

N D Robb

English

Robb, N.D.

Hosey, M.T.

Leitch, J.A.

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OPINIONBRITISH DENTAL JOURNAL  VOLUME 194 NO. 9 MAY 10 2003 469Intravenous conscious sedation in patients under 16 years of age. Fact or fiction?N. D. Robb,1 M.-T. Hosey2 and J. A. Leitch,3Recently published guidelines on the use of conscious sedation in dentistry have published varying recommendations on thelower age limit for the use of intravenous conscious sedation. There are a large number of dentists currently providing dentaltreatment for paediatric patients under intravenous conscious sedation. The 18 cases reported here (age range 11-15 years),were successfully managed with intravenous conscious sedation. The experience in this paper is not sufficient evidence torecommend the wholesale use of intravenous conscious sedation in patients who are under 16 years.  The fact that a range ofoperators can use these techniques on paediatric patients would suggest that further study should be carried out in thispopulation. The guidance should be modified to say there is insufficient evidence to support the use of intravenousconscious sedation in children, rather than arbitrarily selecting a cut off point at age 16 years.1*Senior Lecturer in Sedation in Relation to Dentistry,University of Glasgow Dental School, 2Senior Lecturer inPaediatric Dentistry, University of Glasgow Dental School,3Lecturer in Oral Surgery, University of Glasgow DentalSchool*Correspondence to: N. D. Robb, 378 Sauchiehall Street,Glasgow G2 3JZEmail: n.robb@dental.gla.ac.ukRefereed PaperReceived 10.07.02; Accepted 13.02.03© British Dental Journal 2003; 194: 469–471INTRODUCTION.The use of intravenous conscious seda-tion in patients who are less than 16 yearsof age has been regarded as controversial.Recent guidance has varied between say-ing there is insufficient evidence to rec-ommend the routine use for dentistry1 tosuggestions that it should not be usedexcept in a consultant led service in ahospital environment.2Some of the evidence that is used toback up these assertions is misquoted. TheReport of an Independent Working Party1and the Academy of Medical Royal Collegesreport3 is used to support the use of intra-venous conscious sedation in hospital forchild patients,2 but neither documentmakes any such recommendation.The confusion in the guidelines resultsfrom the fact that there is actually verylittle evidence to either support or con-demn or refute the use of intravenousconscious sedation in patients under theage of 16 years.Informal approaches by the authors toother clinicians involved in teachingconscious sedation revealed that manyclinicians do use intravenous conscioussedation in patients who are under 16years, provided that a full assessment ofthe patient indicates that this would bethe most appropriate management tech-nique.AIMThis paper reports a number of cases ofchildren aged between 11 and 15 whohave been successfully managed underintravenous conscious sedation. It aims toshow that where appropriate, conscioussedation can be used safely and effective-ly in these patients. The authors wish topresent some evidence to open the debateon how to effectively manage paediatricdental patients, especially when alterna-tives to general anaesthesia are beingsought.THE PATIENTSThe sedation teaching facilities at Liver-pool, Cardiff and Glasgow Dental Schoolscarried out a retrospective trawl throughthe appointment books for the academicyear 2001-2002 and reported cases wherechildren between the ages of 11 and 15years were treated. Two cases treated asdemonstrations on a course in Germanywere also included.The cases presented are a selected sam-ple of paediatric patients referred for carewhere the assessing clinician has judgedthat intravenous conscious sedation wasthe most appropriate form of anxietymanagement.● Current guidance indicates intravenous conscious sedation shoulld not be used in children. ● Clinical experience, as presented in these cases, shows it can be a valuable management tool. ● Further research is required to ascertain the role of intravenous sedation in paediatric patients.I N  B R I E F09p469-471.qxd  09/04/2003  11:37  Page 469OPINIONThe sedation technique used, dentaltreatment carried out and any complica-tions were noted. The centres were askedwhether the patients had been starvedprior to treatment. All of the patients,except those treated in Germany, andthree in Glasgow had been allowed to eatuntil at least two hours before treatment.OUTCOME OF TREATMENTThe results are shown in Table 1. All ofthe patients were successfully treated.The outcome was judged to be successfulwhen the patient was able to co-operatewith dental treatment without becomingdistressed. Dental undergraduate studentstreated six of the 18 children as part oftheir training, while staff treated anothersix with undergraduate students observ-ing. Cases 13 and 14 were sedated by oneof the authors (NDR) as part of a courserun in Germany for German dentists.Patients 15 and 16 required exposure ofunerupted maxillary canine teeth. Traineesin surgical dentistry undergoing training insedation techniques treated these patients. A consultant in paediatric dentistryassisted by a consultant anaesthetisttreated patients 17 and 18. This reflectedthe purpose of this list that mixed anx-ious adolescents with learning disabilityadults requiring general anaesthesia.In all cases the patients were consciousthroughout the procedure according tothe General Dental Council definition. Inother words all patients responded to ver-bal command. Eight of the patients had treatmentover multiple appointments, and all were470 BRITISH DENTAL JOURNAL  VOLUME 194 NO. 9 MAY 10 2003happy to receive intravenous sedationhaving experienced it before. None of theparents returning with their childrenreported any problems in the postopera-tive treatment other than tiredness andbruising at the site of venepuncture.Table 1 records the doses of total doses ofmidazolam used. In the case of patients whowere sedated on more than one occasionthe range represents the maximum andminimum doses given during the series ofappointments. The dose of midazolam wastitrated according to standard protocols.4DISCUSSIONThese patients were successfully managedwith intravenous conscious sedation.Dental undergraduate students workingunder supervision treated about half ofthe patients. There were no problems withunexpected loss of consciousness, or fallsin arterial oxygen saturation that mightbe explained by the sedation becomingunpredictably deeper than desired. Noneof these children were disinhibited byintravenous midazolam. The German patients were having pro-phylactic wisdom tooth removal, as rec-ommended by the orthodontist who wastreating them. The German patients,while still able to talk to the surgeon inGerman throughout the procedure, lostthe ability to understand English instruc-tions at a point before a satisfactory levelof sedation could be achieved. Careshould be taken when managing patientswhose first language is not spoken by thesedationist, as communication betweenpatient and sedationist may become diffi-cult. It would appear that the patients areso relaxed that they will not make theeffort to understand a foreign language.The range of operators who successful-ly managed these patients indicates thatthe outcome is not merely related to asingle clinician who happens to be excep-tionally gifted in the management of pae-diatric dental patients under intravenousconscious sedation.There were no problems associated withthe patients having eaten up to two hoursbefore the appointment. The recent guide-lines have suggested that patients shouldbe starved for up to 6 hours.2 There is nojustification for this view in the literature,and further research is required to establishthe correct regime for pre-operative eating.It is the authors’ opinion that the protractedstarving of patients is not only unneces-sary, but is also counterproductive. Longperiods without food make children moreirritable, and may increase the likelihood offainting. It should thus be avoided if it doesnot increase the safety of patient manage-ment.The number of cases reported here isinsufficient to provide evidence to sup-port the routine use of this technique. Thepatients presented are all adolescents (agerange 11-15), and thus this paper shouldnot be used as a justification for patientsoutside this age group. The cases presented cannot be consid-ered as a random or representative sampleof all 11 to 16 year olds requiring dentaltreatment, and who are anxious aboutreceiving care. They have all been assessedas suitable for intravenous conscious seda-Table 1 Patients treated under intravenous conscious sedationStudy number Age at time of treatment Sex Number of appointments Drug used Dose or range Type of treatment Weight (if known) Coments1 11-12 F 5 Midazolam 3-4 mg Cons — Previous Failed RA2 14 F 5 Midazolam 4-8 mg Cons + XLA 61.8 kg Coped very well3 14 M 2 Midazolam 6-7 mg XLA — —4 14 F 1 Midazolam 8 mg Ortho XLA — Second molars5 14 F 1 Midazolam 7 mg XLA 47.3 kg —6 14 F 5 Midazolam 6-8 mg Cons + XLA 61.9 kg Coped very well7 14 M 2 Midazolam 6 mg Endo — Uneventful8 14 F 5 Midazolam 8-10 mg Crowns and cons — Uneventful9 12 — 1 Midazolam 10 mg XLA — —10 13 — 2 Midazolam 10 mg Ortho XLA — Uneventful11 14 — 1 Midazolam 6 mg Cons — —12 15 F 2 Midazolam 5 mg Cons — —13 15 M 1 Midazolam 7 mg Removal of wisdom teeth 70 kg No problems14 14 M 1 Midazolam 6 mg Removal of wisdom teeth 56 kg Slight reaction to ID Nerve block15 13 F 1 Midazolam 4 mg XLA + Exposure of canines — Excellent co-operation. Fasted pre-op16 15 F 1 Midazolam 6 mg XLA + Exposure of canines — Coped very well Fasted pre-op17 13 M 2 Midazolam 5 mg Premolar extractions — uneventful18 13 M 1 Midazolam 9 mg Traumatised tooth — uneventful09p469-471.qxd  09/04/2003  11:40  Page 470tion by the treating clinician, and are thus aselected group. The authors would suggest that there issufficient doubt as to the validity of thecurrent recommendations prohibiting theuse of intravenous conscious sedation inadolescents to justify further research intoits use in this age group of patients.CONCLUSIONFurther research into the use of intra-venous conscious sedation in patientsOPINIONBRITISH DENTAL JOURNAL  VOLUME 194 NO. 9 MAY 10 2003 471under the age of 16 is required. There isinsufficient evidence currently availableto support the routine use of conscioussedation in this age group, but equallythere is sufficient doubt to make anabsolute prohibition of the use of thesetechniques in this age group of patientsunjustifiable. The authors would like to thank Dr ShelaghThompson, Dr Lesley Longman, and Dr WolfgangJakobs for helping with the provision of data for thispaper.1. Standards in Conscious Sedation for Dentistry.Report of an Independent Expert Working Group.October 2000. 2. Safe Sedation of Children Undergoing Diagnosticand Therapeutic Procedures. A national clinicalguideline. Scottish Intercollegiate GuidelinesNetwork. February 20023. Implementing and Ensuring Safe Sedation Practicefor Healthcare Procedures in Adults. Report of anIntercollegiate Working Party chaired by the RoyalCollege of Anaesthetists. Academy of MedicalRoyal Colleges. November 2001.4. Meechan J G, Robb N D, Seymour R A. Pain andAnxiety Control for the Conscious Dental Patient.Oxford: Oxford University Press, 1998 pp 282-285.BDA launches clinical seminars seriesThe first seminar will take place on Saturday 17th May 2003 at The GeneralDental Council, London with the programme being repeated in November inassociation with the Western Counties Branch.Speakers at the seminars, ‘Removable Partial Dentures: Planning,Communicating and Making’ will be two of the authors of the BDJ book ‘AClinical Guide to Removable Partial Dentures’, Professor Robin Basker and JimRalph. The aims and objectives of the day are:The BDA and BDJ are launching a new series of clinical seminars based on the BDJ’s best-selling and authoritative Clinical Guide Series. Seminars will be held throughout the UK andwill give dentists the opportunity to work with clinical leaders on a range of exciting topicshighly relevant to today’s dental practice.The seminar is aimed at dentists and their team including dental technicians and will be limited to 80so you are advised to book early to avoid disappointment. The day will involve group work on treatmentplanning cases which will be illustrated by a history, coloured photos, radiographs and study casts.Fees: Members: £230; Non-Members: £265; Staff/Dental Technicians: £150Further information: Further information on all BDA events can also be seen at www.bda-events.org.uk where you may also now book on-line. You may also book by contactingKatherine Fort on 020 7563 4166.• To highlight the factors which influence the decision whether or not to provide a partial denture and to consider the idea of fewer, better dentures.• To provide an opportunity for hands-on treatment planning and design followedby discussion of delegates’ opinions.• To present the available evidence on how dentists communicate with dental technicians and to consider the role of the computer in communication.• To consider the principles of denture design which promote good oral healthand which lead to the construction of stable dentures for common situations.• To demonstrate impression techniques for the sublingual bar and for lowerdistal extension saddles.• To discuss the role of the RPD in managing the growing problem of tooth surfaceloss.BDA/BDJ Clinical SeminarsRemovable PartialDentures: Planning, Communicating and MakingSaturday 17th May 2003General Dental Council, 37 Wimpole Street, London, W1G 8DQIn partnership with Poli-Grip  NEW FOR 200309p469-471.qxd  09/04/2003  11:41  Page 471

Intravenous conscious sedation in patients under 16 years of age. Fact or fiction?

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Intravenous conscious sedation in patients under 16 years of age. Fact or fiction?

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