Chloral hydrate is a long-standing and effective sedative hypnotic. Its use in children's
dentistry has been well researched, it has a good margin of safety, causes little or no
respiratory depression at therapeutic levels, and has few serious side-effects. The
optimum dosage is 30-50 mg/kg, up to a maximum of 1.0 g. However, its bitter taste
makes it unpleasant to take and it is a potent gastric irritant, producing vomiting in
many children. This not only has the potential to increase the child's distress, but also
reduces the efficacy of the drug. Trichlofos, a derivative of chloral hydrate, causes
less gastric irritation, but otherwise appears to produce similar results, although there
has been little research to confirm this.
Benzodiazepines
Many benzodiazepines have been investigated as potential sedation agents for use in
children's dentistry. They have a wide therapeutic index and can be reversed by
flumazenil. Diazepam can be used for oral sedation, but produces prolonged sedation
and has proved somewhat unpredictable in young children. Temazepam was popular
some years ago, especially as its duration of action is shorter than diazepam.
However, idiosyncratic reactions in some children have caused temazepam to fall
from favour. In the UK, temazepam also has the disadvantage of being a Schedule 3
controlled drug.
Recent studies using midazolam, another short-acting benzodiazepine, have reported
good results. Midazolam is easy to take orally and seems to offer safe and reliable
sedation, with far fewer idiosyncratic reactions than with temazepam. Onset of
sedation is rapid (around 20 minutes) and recovery is also relatively quick. The
optimum dose is 0.3-0.5 mg/kg when given orally. The preparation designed for
intravenous administration is used, often mixed into a small volume of a suitable fruit
drink. Some studies report successful delivery via the nasal mucosa, where doses of
0.2-0.3 mg/kg have been advocated. However, midazolam is not yet available as an
oral or nasal preparation and is not yet licensed for oral sedation. Practitioners are
therefore advised to seek specific training before prescribing midazolam for oral
sedation.
When using any sedative agent in children it is essential that suitable precautions are
taken and that appropriate emergency drugs and equipment are available. These
important aspects are detailed fully in 297HChapter 4 and, hence, will not be further
rehearsed here.
7.7.4 General anaesthesia
Dental extraction under general anaesthesia has been used widely in the UK as a
strategy for the treatment of dental caries in preschool children. Recently, the
justification for such extensive use has been questioned, and it is now widely agreed
that general anaesthesia should only take place in hospital and should only be
employed where other behaviour management strategies have failed or are
inappropriate. General anaesthesia is, however, indicated for some child patients.
Comprehensive full mouth care under intubated general anaesthesia enables children
with multiple carious teeth to be expediently rendered caries-free in one procedure
(298HFig. 7.7). This approach does have a place in the management of young, anxious, or