Guest Editorial: Ensuring Safety During Pediatric Dental Treatment

There is no greater tragedy than losing a child. It is unnerving for everyone—especially oral health professionals—to hear of children dying as a result of dental treatment that included procedural sedation and/or general anesthesia. Such instances serve as reminders that the dental team is responsible for ensuring the safety of patients. Thoroughly explaining the risks and safeguards in place during anesthesia is important for the compliance and peace of mind of parents and caregivers.

Most children will respond positively to behavior guidance techniques such as the ubiquitous “tell, show, do” approach; however, some pediatric patients may present with behavioral considerations that require more advanced methods of management. These children often cannot cooperate due to a lack of psychological or emotional maturity and/or mental, physical, or medical disability.¹ Procedural sedation and general anesthesia are among these advanced behavior guidance techniques used to enable the provision of oral health care services.

Studies have shown that while pediatric patients tend to have higher rates of adverse outcomes from general anesthesia than adults, approximately one-third of anesthesia-related negative events are due to post-operative nausea and vomiting (in children older than 5).² Another study estimated the number of adverse anesthetic outcomes in developed countries at 0.41 to 6.8 per 10,000 anesthetic administrations.³ Most cases of anesthesia-related mortality were associated with airway and cardiovascular events. Thorough preoperative and intraoperative assessments are key in keeping patients safe. Infants age 12 months and younger are at increased risk for adverse outcomes during or after the administration of procedural sedation and general anesthesia.⁴ Thus, the highest level of vigilance must be implemented when treating these young patients.

The American Academy of Pediatric Dentistry (AAPD) and the American Academy of Pediatrics assert that obtaining informed consent is a key part of providing procedural sedation/general anesthesia. Oral health professionals should effectively communicate behavior and treatment options, including potential benefits and risks, and help parents and caregivers decide what is in the child’s best interest.⁵ Members of the dental team need to be fully prepared to discuss the reasons a treatment is recommended; explain safety precautions that will be undertaken; and outline the emergency plan that will be implemented in the event of an adverse outcome. Clinicians should be prepared to provide pediatric life support when procedural sedation is administered to children. Dental team members, including dental hygienists, should be proficient in using the bag-valve mask to provide quality ventilation when needed.

ROLE OF DENTAL HYGIENISTS

Dental hygienists play an important role in reassuring parents and caregivers whose children are to receive sedation before a dental procedure. Offices should have a standard protocol to ensure parents/caregivers understand the sedation process. It should be clear that the medication is designed to decrease anxiety about receiving dental treatment and will leave patients without memories of the procedure. Parents and caregivers must be informed that children’s vital signs will be monitored before, during, and after the procedure. Some offices invite parents and caregivers to accompany their children into the operatory. Once the medication has been administered, however, parents and caregivers should be directed to the waiting room, where they will remain until the procedure is completed.

Dental hygienists should provide parents and caregivers with in­structions leading up to the sedation appointment. If patients become ill with a respiratory issue (eg, cold, fever, stuffy nose, flu) a week or less before the scheduled sedation, the appointment should be rescheduled because respiratory illnesses raise the risk of adverse events. Furthermore, parents and caregivers need to be informed that patients should not ingest any food after midnight before the scheduled procedure because this increases the risk of aspirating vomit into the lungs. The American Society of Anesthesiologists recommends that patients stop consuming clear liquids 2 hours prior to the procedure, breastmilk 4 hours before, and food 8 hours prior. The day of the sedation, clinicians should follow up with parents and caregivers concerning the child’s health and last intake of food or liquids. On the day of the visit, it is best to have two adults present so one adult can ensure the child’s head is properly elevated during the drive home in order to effectively maintain his or her airway. Children need to be dressed in comfortable clothes and may also want to bring a stuffed animal or favorite blanket.

Every day in the United States thousands of children are successfully sedated or put under anesthesia to manage dental disease with uneventful outcomes. The burden of dental disease has shifted to a much younger age group than previous generations, and attention to detail is critical in providing safe care.

Adverse outcomes associated with procedural sedation and general anesthesia can be prevented by carefully adhering to the AAPD clinical guidelines and recommendations, which were created in collaboration with the American Academy of Pediatrics; installing in-office safety measures and risk management procedures; and providing clear communication between parents/caregivers and dental team members about the risks, benefits, and alternatives to treatment.

References

1. American Academy of Pediatric Dentistry. Guideline on Behavior Guidance for the Pediatric Patient. Available at: aapd.org/media/policies_guidelines/g_behavguide.pdf. Accessed June 17, 2016.
2. Cohen MM, Cameron CB, Duncan PG. Pediatric anesthesia morbidity and mortality in the perio perative period. Anesth Analg. 1990;70:160–167.
3. Gonzalez LP, Pignaton W, Kusano PS, Módolo NS, Braz JR, Braz LG. Anesthesia-related mortality in pediatric patients: a systematic review. Clinics (Sao Paulo). 2012;67:381–387.
4. Lee HH, Milgrom P, Starks H, Burke W. Trends in death associated with pediatric dental sedation and general anesthesia. Paediatr Anaesth. 2013;23:741–746.
5. Chen AH, Youdelman MK, Brooks J. The legal framework for language access in healthcare settings: Title VI and beyond. J Gen Intern Med. 2007;22(Suppl 2):362–367.

From Dimensions of Dental Hygiene. July 2016;14(07):20–21.