Oral Conscious Sedation - the why, the what and the who.
One crucial aspect of a pediatric dental residency is learning behaviour guidance. Being able to treat a child with non-pharmacological means is very rewarding. However, for those who are pre-cooperative or need extensive treatment which may lead to many unpleasant visits, we need more tricks up our sleeve.
Oral conscious sedation (OCS) is one such pharmacological means of guiding behavior and gaining cooperation from our little ones.
It can be single drug or multi-drug. Whether or not a pediatric dentist can offer this service depends on two factors -
Where were they trained? and,
Where are they practicing?
Many states in the US and provinces in Canada, have banned provision of oral conscious sedation in dental offices. I will discuss the reason for this in a future post so stay tuned! The pediatric dental residents in those states/provinces, hence, are unable to receive the training to provide this service.
Even if a pediatric dentist receives this training in their residency, if they practice in a state or province that does not allow OCS, they are not able to provide it to their patients.
I was not aware of this limitation when I applied to residency. Fortunately, British Columbia allows moderate oral conscious sedation delivery in dental offices under the supervision of a trained pediatric dentist.
Next question is - which pediatric patient qualifies for this?
First let us review what oral conscious sedation is -
💊 Minimal sedation is a minimally depressed level of consciousness in which the patient responds normally to tactile stimulation and verbal command. It is produced by a pharmacological method such as an oral sedative that you can take before a dental procedure.
💊 Moderate sedation is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light touch.
In both cases, the patients are breathing on their own. Their vitals are being monitored. In my residency, we monitor BP, O2 saturation, Pulse, Heart Rate and End Tidal CO2. Some providers use a precordial stethoscope where they can hear the patient’s chest sounds throughout the procedure.
The pediatric dentist in this situation is both the operating dentist and “the anesthetist.” One needs two auxiliary personnel, an assistant and a scribe who is noting the vitals every 5 minutes.
During pre-op sedation assessment, the following patients would make ideal candidates -
🩺 ASA I or II
💪🏼 5th percentile < BMI > 95th percentile
🦷 Able to take intraoral radiographs
🩺 Clear chest sounds.
👅 Tonsils less than 50% according to Brodsky grading.
🦷 2 or more quadrants of restorative work.
💊 Able to take oral medications (meds can be syringed in the back of the throat but patient has to be able to swallow it).
🤒 No recent upper respiratory infections (cough/cold/congestion).
😡 Not defiant or extremely fearful
Pt has to be NPO for at least 8 hours prior to the procedure.
Oral medication is given according to weight. Using nitrous oxide concurrently helps achieve more profound sedation.
Pt has to be alert and oriented prior to leaving the office with two adults.
Oral conscious sedation can be a valuable tool for many patients. It is more affordable than General anesthesia and if done correctly, can be just as safe. If a patient is still not able to tolerate treatment with OCS, General Anesthesia is the preferred option.