Understanding Pain Control Choices in Dentistry for Children

Taking a child in to the dentist to have a dental “cavity” or carie restored is an emotional and stressful endeavor for both the child and the parents.  For many, it can also be confusing.  What are the choices?
For some children, local anesthetic is enough to get the job done.  
Local anesthesia is the temporary loss of sensation or pain in one part of the body produced by a topically applied or injected agent.  It does not depress or alter the level of consciousness.  It numbs the gums and/or teeth and gives you that “fat lip” feeling.  But, it helps to prevent discomfort and pain during dental treatment.  

Usually, a topical anesthetic is applied first to help numb the surface of the gums and can be applied with a cotton swab, spray, or adhesive patch.  It helps to eliminate the sting or prick from the injection.  The injection works to prevent pain by blocking nerve endings and temporarily numbs mouth tissues in the area that is being treated.  Since the child’s tongue and/or lip may remain numb for several hours after the procedure, parents should carefully monitor their child to prevent them from accidentally biting and injuring their lip or tongue until the effects of the local anesthetic wear off.

However, even with the best intentions and verbal skills of the dentist and the dental staff, some children cannot be calmed enough into accepting dental treatment.  Unfortunately, unlike the flu, dental problems do not go away.  If left untreated, they progress and get worse, and can even eventually require hospitalization.  So, when a child requires dental treatment, but is too anxious or fearful to allow treatment to be done, some sort of antianxiety agent or sedation can help.  Remember, too, that the dentist wants to make sure that the dental visit is as free from discomfort and anxiety as possible for the child.

The decision for sedation should be by informed consent.  That means that the dentist has verbally described all the options, given his recommendation and reasons, and explained why he feels what he has chosen is best for your child.  Some children that may require sedation are:
•    Infants, toddlers, or very young children.
•    Very anxious or fearful children.
•    Children who have had previous bad experiences in a dental office.
•    Children with special needs.
•    Children with compromised health.
•    Children requiring extensive work.

Antianxiety agents or sedatives may be used with local anesthetics and pain medications which can help the child or young adult to relax during dental procedures.  They may be given before or during the dental appointment, and can be given as pills, liquids, or injections.  Some are inhaled.  It is very important to:

•    Inform the dentist regarding the health status of the child.
•    List any medications the child may be taking.
•    Notify the dentist of any drug allergies.
•    Follow the dentist’s pre and post sedation instructions.

Conscious sedation is a minimally depressed state of consciousness.  The patient/child will be relaxed and sleepy but will remain awake and be able to respond to physical stimulation and simple verbal commands.  Sedation effects can last for up to four hours, and minor side effects such as nausea or vomiting may occur with some medications.

For children who are mildly or moderately anxious, nitrous oxide or “laughing gas” is most often used.  The gas is breathed in through a mask worn over the child’s face during the dental procedure.  It eases their fears and helps them to relax and accept treatment comfortably and safely.  As the gas begins to work and the child becomes calm, the child is, at the same time, awake and able to talk to the dentist.  The effects of nitrous wears off within a few minutes of being turned off.  As the child gets older and becomes comfortable with the dentist, nitrous may no longer be needed.  

Although nitrous gas is safe, delivered easily, and the effects disappear rapidly, it can make a child feel nauseous.  Therefore, it is best that a child requiring this type of sedation not eat beforehand.  For children who are more anxious, or for children with congestion or breathing problems, other types of sedation may be suggested.

Oral medication may be recommended for more anxious children, and is stronger than nitrous oxide.  The oral route is the oldest and most commonly used.  Children having oral sedation will be sleepy, but can be aroused and are able to respond to commands.  The most widely used oral sedation for children is Versed (Medazolan), which is a liquid.  The disadvantage of this type of sedation is that the level of sedation for each person is not always predictable.  Again, nausea or vomiting may occur, so it is important to follow the directions you receive from your dentist regarding instructions about what to eat or drink before and after the appointment.

Other Methods of Conscious Sedation may be delivered in alternative ways, such as by suppository, by injection, or intravenously (into a vein).  These methods require more experience to be administered and monitored properly.  Injections and intravenous medications should be used only by dentists with extensive training in these techniques.

General Anesthesia may be necessary for children who cannot relax or calm down enough for treatment to be completed safely.  General anesthesia puts a child to sleep.  This is the same kind of deep sleep a child would have if he/she were to have their tonsils removed or ear tubes placed.  While the child is under general anesthesia, he or she is unable to feel pain or move around.  Other reasons why your dentist may feel your child is a candidate for general anesthesia include:
•    Child needs oral surgery or other dental treatment that would be difficult to tolerate while awake.
•    There is an extensive amount of dental work to be done that may be best when done in one long appointment rather than multiple visits.
•    Child has a medical, physical, or emotional disability that limits his or her ability to understand directions and be treated safely.

Although general anesthesia is often the best choice in these cases, it also carries some risk.  It is important to discuss the risks and benefits with your dentist to understand why it might be best for your child.  This type of anesthesia for dental procedures can be administered by an anesthesiologist, dental anesthesiologist or an oral/maxillofacial surgeon.  These are professionals who have had the extra training to be able to deliver the medications, monitor the child during the procedure, and are also able to handle any complications that may occur.

Your child will need a physical examination before receiving general anesthesia to make sure there are no contraindications for receiving this type of sedation.  If your child becomes ill on the day of the scheduled appointment, call to see if it would be better for the appointment to be rescheduled for when the child is well.

Again, it is very important to follow the directions given by the dentist for both before and after the appointment.  It is recommended that you let your child rest quietly at home for the remainder of the day.  He or she will probably be ready to resume his or her normal routine the following day.

If there is a choice between not having the work done and having it done with sedation, choose to have the work done.  As stated previously, dental problems do not go away by themselves, and usually progress.  The sooner something is treated, the easier and less invasive it will be.  Search or “google”  For Want of a Dentist, to see Washington Post’s article about Deamonte Drover and how serious dental problems can become, if left untreated.  Although thankfully, dental related problems in children do not often lead to this fatal outcome, they can (and do!) cause pain, loss of appetite, and loss of sleep, which can affect their ability to focus and learn, their speech, and their self-esteem.

Other sources:

www.ada.org

www.childrens-dentist.com/sedationdentistry_children.html


www.qualitydentistry.com/dental/SedationDentistry/sedation.html


www.aapd.org/publications/brochures/anesthesia.asp

www.cda.org/popup/General_Anesthesia_and_Oral_Sedation


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