and, where appropriate, with the child. For example, the younger the child the greater
the likelihood of a need for general anaesthesia. At the other end of the age range it is
unlikely that a 15-year old will need general anaesthesia for simple orthodontic
extractions, although this might be required for moderately complex surgery, such as
exposing and bonding an impacted canine. The degree of trauma involved is also
another factor; a single extraction is most likely to be carried out under local
anaesthesia, removal of the four first permanent molars is most likely to be carried out
under general anaesthesia. Anxiety perceived as excessive, especially after an attempt
at treatment under local anaesthesia and sedation, would lead to simple treatment such
as conservative dentistry being carried out under a general anaesthetic usually
involving endotracheal intubation. Serious medical problems, for example, cystic
fibrosis with the associated respiratory problems would justify using sedation instead
of general anaesthesia even for more traumatic surgery, such as removal of impacted
canines, but it would be appropriate to carry out this sedation in a hospital
environment. The degree of intellectual and/or physical impairment in handicapped
children would also be a factor to be considered.
General anaesthesia carries with it a finite risk of serious morbidity such as
psychological trauma and even death (3 to 4 per million). No child should be
submitted to a general anaesthetic without consideration of this potentially devastating
outcome. Intermediate between the minimally intrusive techniques of local
anaesthesia and the major intrusion of general anaesthesia are the techniques of
conscious sedation (Fig. 4.1).
Key Points
- Each child should be assessed on their merits and an appropriate method of pain
control used. - The vast majority of children are amenable to satisfactory treatment using behaviour
management and local anaesthesia alone. - No child should be submitted to a general anaesthetic without consideration of
potential risk.
4.7 CONSCIOUS SEDATION TECHNIQUES
4.7.0 Introduction
Conscious sedation is defined as:
A technique in which the use of a drug or drugs produces a state of depression of the
central nervous system enabling treatment to be carried out, but during which verbal
contact with the patient is maintained throughout the period of sedation. The drugs
and techniques used to provide conscious sedation for dental treatment should carry a
margin of safety wide enough to render unintended loss of consciousness unlikely.
The level of sedation must be such that the patient remains conscious, retains
protective reflexes, and is able to understand and respond to verbal commands.
The routes of administration of sedative drugs used in clinical paediatric dentistry are
oral, inhalational, intravenous, and transmucosal (e.g. nasal, rectal, sublingual).
However, the transmucosal routes are little used in the United Kingdom and currently,
intravenous sedation is considered unsuitable for the operator/sedationist when