Introduction.

The use of intravenous conscious sedation in patients who are less than 16 years of age has been regarded as controversial. Recent guidance has varied between saying there is insufficient evidence to recommend the routine use for dentistry1 to suggestions that it should not be used except in a consultant led service in a hospital environment.2

Some of the evidence that is used to back up these assertions is misquoted. The Report of an Independent Working Party1 and the Academy of Medical Royal Colleges report3 is used to support the use of intravenous conscious sedation in hospital for child patients,2 but neither document makes any such recommendation.

The confusion in the guidelines results from the fact that there is actually very little evidence to either support or condemn or refute the use of intravenous conscious sedation in patients under the age of 16 years.

Informal approaches by the authors to other clinicians involved in teaching conscious sedation revealed that many clinicians do use intravenous conscious sedation in patients who are under 16 years, provided that a full assessment of the patient indicates that this would be the most appropriate management technique.

Aim

This paper reports a number of cases of children aged between 11 and 15 who have been successfully managed under intravenous conscious sedation. It aims to show that where appropriate, conscious sedation can be used safely and effectively in these patients. The authors wish to present some evidence to open the debate on how to effectively manage paediatric dental patients, especially when alternatives to general anaesthesia are being sought.

The patients

The sedation teaching facilities at Liverpool, Cardiff and Glasgow Dental Schools carried out a retrospective trawl through the appointment books for the academic year 2001-2002 and reported cases where children between the ages of 11 and 15 years were treated. Two cases treated as demonstrations on a course in Germany were also included.

The cases presented are a selected sample of paediatric patients referred for care where the assessing clinician has judged that intravenous conscious sedation was the most appropriate form of anxiety management.

The sedation technique used, dental treatment carried out and any complications were noted. The centres were asked whether the patients had been starved prior to treatment. All of the patients, except those treated in Germany, and three in Glasgow had been allowed to eat until at least two hours before treatment.

Outcome of treatment

The results are shown in Table 1. All of the patients were successfully treated. The outcome was judged to be successful when the patient was able to co-operate with dental treatment without becoming distressed. Dental undergraduate students treated six of the 18 children as part of their training, while staff treated another six with undergraduate students observing. Cases 13 and 14 were sedated by one of the authors (NDR) as part of a course run in Germany for German dentists.

Table 1 Patients treated under intravenous conscious sedation
Full size table

Patients 15 and 16 required exposure of unerupted maxillary canine teeth. Trainees in surgical dentistry undergoing training in sedation techniques treated these patients.

A consultant in paediatric dentistry assisted by a consultant anaesthetist treated patients 17 and 18. This reflected the purpose of this list that mixed anxious adolescents with learning disability adults requiring general anaesthesia.

In all cases the patients were conscious throughout the procedure according to the General Dental Council definition. In other words all patients responded to verbal command.

Eight of the patients had treatment over multiple appointments, and all were happy to receive intravenous sedation having experienced it before. None of the parents returning with their children reported any problems in the postoperative treatment other than tiredness and bruising at the site of venepuncture.

Table 1 records the doses of total doses of midazolam used. In the case of patients who were sedated on more than one occasion the range represents the maximum and minimum doses given during the series of appointments. The dose of midazolam was titrated according to standard protocols.4

Discussion

These patients were successfully managed with intravenous conscious sedation. Dental undergraduate students working under supervision treated about half of the patients. There were no problems with unexpected loss of consciousness, or falls in arterial oxygen saturation that might be explained by the sedation becoming unpredictably deeper than desired. None of these children were disinhibited by intravenous midazolam.

The German patients were having prophylactic wisdom tooth removal, as recommended by the orthodontist who was treating them. The German patients, while still able to talk to the surgeon in German throughout the procedure, lost the ability to understand English instructions at a point before a satisfactory level of sedation could be achieved. Care should be taken when managing patients whose first language is not spoken by the sedationist, as communication between patient and sedationist may become difficult. It would appear that the patients are so relaxed that they will not make the effort to understand a foreign language.

The range of operators who successfully managed these patients indicates that the outcome is not merely related to a single clinician who happens to be exceptionally gifted in the management of paediatric dental patients under intravenous conscious sedation.

There were no problems associated with the patients having eaten up to two hours before the appointment. The recent guidelines have suggested that patients should be starved for up to 6 hours.2 There is no justification for this view in the literature, and further research is required to establish the correct regime for pre-operative eating. It is the authors' opinion that the protracted starving of patients is not only unnecessary, but is also counterproductive. Long periods without food make children more irritable, and may increase the likelihood of fainting. It should thus be avoided if it does not increase the safety of patient management.

The number of cases reported here is insufficient to provide evidence to support the routine use of this technique. The patients presented are all adolescents (age range 11-15), and thus this paper should not be used as a justification for patients outside this age group.

The cases presented cannot be considered as a random or representative sample of all 11 to 16 year olds requiring dental treatment, and who are anxious about receiving care. They have all been assessed as suitable for intravenous conscious sedation by the treating clinician, and are thus a selected group.

The authors would suggest that there is sufficient doubt as to the validity of the current recommendations prohibiting the use of intravenous conscious sedation in adolescents to justify further research into its use in this age group of patients.

Conclusion

Further research into the use of intravenous conscious sedation in patients under the age of 16 is required. There is insufficient evidence currently available to support the routine use of conscious sedation in this age group, but equally there is sufficient doubt to make an absolute prohibition of the use of these techniques in this age group of patients unjustifiable.