Pharmacological Management of the Pediatric Patient

Resident: Adam J. Bottrill
Date: 19JAN11
Region: Providence
Article title: Pharmacological Management of the Pediatric Patient
Author(s): Wilson, Stephen DMD, MA, PhD
Journal: Pediatric Dentistry
Page #s: 131-135
Vol:No Date: 26:2, 2004
Major topic: Behavior Management, Sedation, General Anesthesia
Minor topic(s): NA
Type of Article: Conference Paper

Main Purpose: Provide an overview of the various forms of pharmacological management of pediatric dental patients.

Key points in the article discussion:

I. General:

A. Society demands not only efficient, but HUMANE ways of administering behavior management.
B. Only ONE behavior management technique is consistently taught at ALL residency programs in the US... Pharmacological Management (PM).
1. PM is generally divided into two categories: Sedation and GA.
2. Hundreds of articles written about sedation... much less about GA.
C. Factors to be considered when considering PM.
1. Risks
2. Safety Record
3. Extent of dental needs
4. Practitioner competence
5. Professional support for technique
6. Monitoring
7. Cost
8. Venue
9. Parental expectations
10. Child's needs and personality
11. Integration of these factors into MO embraced by profession

II. Sedation Risks and Safety.
A. Major: brain damage and death
B. Minor: vomiting, behavior, extreme physiological parameters
C. COMPLETE med history is imperative.
1. airway issues (snoring etc...)
2. allergies
3. review of systems
4. Only children with very MILD conditions should be considered for sedation.
D. AIRWAY AIRWAY AIRWAY
E. Though pediatric patients have died due to sedation, there is no evidence that suggests death has occurred when practitioners are faithfully following guidelines.
F. It is NOT POSSIBLE to accurately calculate an official safety record WRT sedation. There is no way to generate an accurate number of SUCCESSFUL sedation attempts.

III. PM Cost and Reimbursement issues

A. Significant issue effecting choice of sedation
B. Medicaid covers enough to "break even" in most states.
C. GA is OFTEN covered for "equivalent" medical procedures.
D. So why the disparity???

IV. Training Issues

A. Risk may INCREASE with sedation (when compared to GA) due to lack of training or adherence to sedation guidelines.
B. Dental students are often not trained in deep sedation techniques due to the lack of knowledge and experience of faculty.
C. There seems to be a general attitude of "It won't happen to me" among dentists using sedation.
D. Solutions: MORE TRAINING, Resolution of the financial/political issues associated with GA

V. Professional Issues

A. Subtle professional pressures by medical anesthesiologists for the independence in the roles the roles of operator and anesthetist.
B. The author blames "financial considerations".
C. 2 or more sedation cases costs MORE than one GA case.
D. Controversy over HOM and "voice control"
E. General disagreement and lack of communication between AAP, AAPD and medical anesthesiologists.

VI. Societal and Parenting Issues

A. Parents no longer implicitly trust practitioners
B. Parental expectations are sometimes rediculo.
C. Recent surveys of AAPD members have shown that the general perceived behavior of children has deteriorated over the last few decades.
1. This correlates with the general increase in the necessity of sedation over the past few decades.

VII. Conclusions

A. GA for the healthy fearful child is extremely safe.
B. Some medical specialists are opposed to use of GA outside of the hospital however "little evidence supporting such an opinion is available."
C. PM of the pediatric patient is acceptable and desirable.
D. What is needed:
1. MORE RESEARCH ENDEAVORS
2. Dissemination of accurate information to communities
3. Collaboration of medical and dental organizations.
4. Political and business initiatives.
5. Further efforts to minimize dental disease.

Assessment of article: I'm not a huge fan of the "Conference Paper." Very opinionated and anecdotal. Not really of much use clinically.