Children who need conscious sedation usually receive treatment from a certified pediatric specialist because most general dentists may not be prepared to treat children ages two through six who have rampant decay or developmental disabilities. It is very important for a dentist to recognize early on that his or her patient may require more management skills than he or she is equipped to offer.
A spin-off of our children’s access to care campaign, this column now focuses on specialized care and education for young patients.
The pediatric practice I work with—Westchester Pediatric Dentistry of White Plains, N.Y.—often receives referrals from other offices after an attempt to treat these complex cases in their own practice has already been made. In some cases, this is done to retain the revenue for their office. This is ill-advised, however, since by treating fearful children without the knowledge and resources of a specialist, irreparable harm can be done to a child’s psyche. By the time children in these situations reach our office, it is hard to gain their confidence and trust. Often, this is especially difficult for parents to endure. After learning about their child’s teeth, the parents are often riddled with guilt and they wish they would have acted sooner—the added stress of a child in distress is a huge burden.
Our office specializes in treating young patients who may have special needs, both in the amount of help they may require and with developmental disabilities. The space and the experience is designed so that, from the moment a child enters our practice, he or she recognizes this place is especially for kids. Parents have an opportunity to fill out a new patient packet early, and all new families are interviewed over the telephone in advance to help us prepare for their visit. The packets include a DVD that gives the child an opportunity to become familiar with our office surroundings in the comfort of their own home.
The morning of the first visit, the dental hygienist sits down with the parents and gathers the dental and medical history of the child patient. Thorough dietary counseling also is provided, emphasizing that children who have high carbohydrate diets and drink juice continually throughout the day are more prone to dental decay.
After the emotional and mental preparation—for both parent and child—is complete, we are ready to provide the necessary care. For example, in early January, Jimmy, age 6, was referred to our office. His parents had checked him into the local emergency room the day before because of severe pain in his left ear. The pediatrician on call examined him and reported to us that he had facial cellulitis with redness and swelling in his left cheek, and thought it was more likely a dental-related problem.
Jimmy’s medical history stated that he had Attention Deficit Hyperactivity Disorder, Obsessive-Compulsive Disorder, that he undergoes speech therapy, and sees a child psychologist privately and in school. He is not taking any medications and has no allergies.
Although he was noticeably frightened, he cooperated, and we were able to take the needed radiographs—a panoramic view, two bitewings and one periapical of the infected area. He was given a preventive prophylaxis, fluoride treatment, and full examination. Dr. Minerva Patel, who is experienced treating children with special needs, found Jimmy had advanced decay in all four quadrants, with a large fistula in the upper left quadrant.
Due to the extent of Jimmy’s decay, Dr. Patel—along with Jimmy’s parents—decided to treat him using conscious sedation. “Conscious sedation is a nice adjunct for young children who are afraid and need extensive work,” Dr. Patel explains. “Overall, it is a more positive experience.”
Jimmy was given a prescription for 250mg of amoxicillin, to be taken every eight hours. Preoperative instructions were given to the parents, questions were answered, and Jimmy’s appointment was scheduled for the following week. Before leaving the office, we made sure that his parents had a good understanding of what to expect, and how much the procedure would cost; the plan was to complete all the treatment during the following visit.
When Jimmy arrived for his scheduled appointment, Dr. Patel began to prepare his sedative medication. All sedative medications administered orally are based on the child’s weight, to minimize the chance of an overdose. Before beginning any treatment, all comprehensive forms were signed, giving Dr. Patel permission to treat Jimmy and confirming the parents agreed to the cost, understood the procedure, and had their questions answered.
All Jimmy’s vital signs were recorded every 15 minutes before, during and after treatment, including end-tidal carbon dioxide concentration in the expired air (ETCO2), the amount of oxygen being carried by the red blood cells in the blood (SpO2), pulse, respiration, color, movement, crying, sleep, and blood pressure. The procedure was monitored carefully with sophisticated equipment, similar to a hospital. In addition to the oral medication, Nitrous Oxide also was used for patient management.
Jimmy was wrapped in towels to keep him warm and secure, and a pillow was used to hold his head in position. His medication was taken at 8:20 a.m., treatment started 9:30 a.m., all treatment was completed and the patient was dismissed at 11:15 a.m. The patient was conscious and interactive during treatment. Dr. Patel’s spirits were high and very encouraging toward Jimmy to match his temperament. Often, children will take naps during the procedure, but not Jimmy. Thankfully, because of the amnesia effect of the medication, Jimmy will not remember much of his experience.
After the procedure, our office sent Jimmy a card encouraging him and thanking him for completing his dental work. We plan to see him in three months for an examination, prophylaxis, and fluoride varnish, as well as to follow up on how he is doing with his homecare and new nutritional guidelines.