Emergencies for Pediatric Dentistry


Nitrous Oxide

Although nitrous oxide is commonly called “laughing gas," it rarely makes your child laugh. It is a very safe drug with children and is a very good analgesic (pain reliever) and anxiolytic (anti-anxiety) agent with the added benefit of being administered with 50% oxygen. The American Academy of Pediatric Dentistry recommends this safe and effective technique to reduce anxiety and enhance effective communication with anxious children about to undergo dental treatment.

The purpose of nitrous oxide sedation is to reduce anxiety, enhance communication, increase the pain threshold, increase tolerance for longer procedures, promote amnesia and inhibit the gag reflex. Nitrous oxide is generally indicated for nervous, fearful children and those undergoing restorative procedures where local anesthesia is required.

Nitrous oxide has many desirable properties: It has a rapid onset of action, the depth of sedation is easily adjusted specifically to your child’s needs and it has a rapid and complete recovery (approximately three minutes). The most common side effect with nitrous oxide is nausea and vomiting. Contraindications with children are few. Wild Smiles offers nitrous oxide sedation at no charge because it makes for a more pleasant treatment visit for our patients. Happy children make for happy doctors!

In-Office Sedation

At Wild Smiles the vast majority of children easily tolerate restorative dentistry using local anesthetics with the aid of supplemental nitrous oxide administration. However, an in-office sedation approach is sometimes helpful in accomplishing care with very young children or those children with substantial fears and dental needs.

The doctors at Wild Smiles are pediatric dental practitioners who are trained in providing in-office sedation. We are not only licensed by the State of Tennessee, but also have a specialized sedation permit that is required to offer this approach. The sedation permit requires sedation certification, ongoing continuing education, as well as stringent office and doctor criteria established by the State of Tennessee. We follow guidelines established by the American Academy of Pediatric Dentistry and are shared with the American Academy of Pediatrics to ensure against adverse events. Wild Smiles doctors have been using in-office sedation for many years and have never had an adverse effect because all safety measures and protocols are ALWAYS taken.

The goal of an in-office sedation approach is to safely accomplish necessary dental treatment as gracefully as possible by using a medication that minimizes the potential for negative memories toward future dentistry. Our office employs two sedation protocols that are proven safe and effective. One employs a Valium based drug called Versed®, used in combination with Hydroxyzine (an anti-histamine) and Advil® to create a minimal to moderate state of sedation. The second protocol includes Demerol in a sedative combination cocktail with Hydroxyzine to create a moderate state of sedation. These medications have a rapid onset and you will quickly see the sedative effects.

During the procedure, nitrous oxide and oxygen will be used to enhance the sedative and amnestic properties of these sedative medications while also supplying supplemental oxygen. Your child will not be unconscious and may occasionally cry during the procedure. This does not mean your child is hurting as the teeth will be completely anesthetized with a local anesthetic. The doctor and assistant will be taking care of your child and he or she will be continuously monitored with pulse oximetry and other monitoring devices.

When the treatment is complete, parents are reunited with the patient for the recovery and observation period. During this time, postoperative instructions are reviewed and questions answered. The family is allowed to leave when standard discharge criteria are met.

This following is intended to answer common questions concerning our in-office sedation protocol and provide information that will be helpful before, during, and after your child’s appointment. Should you have specific questions, please feel free to call and talk with either the treatment coordinator or the doctor.

Before the Appointment

1) No eating or drinking after midnight before the appointment; the sedative medications work best on an empty stomach. The medicines may cause nausea and vomiting and an empty stomach reduces the chances of this happening.

2) Report use of other medications: Notify us of any medicines given to your child within 24 hours of the sedation appointment. Any daily medication that is used at the direction of a physician should be given with only a sip of water.

3) Report any change in health status: Should your child have a cold, runny nose, cough, or fever within two days of the sedation appointment, it may be necessary to reschedule the appointment. For your child’s safety, please call if there is any change in your child’s health before the appointment.

4) Call if unable to keep the appointment: Since a minimum of two hours has been reserved exclusively for your child, it is extremely important to keep your scheduled appointment. With your cooperation, we will be able to provide more efficient care for your child and others.

5) Adult supervision: Since you will have to closely attend to your child after the sedation appointment, we strongly recommend a second adult travel with you. In addition, it would be best to leave other children at home.

During the Appointment

1) Arrival: Upon arrival, your child will be weighed and vital signs recorded. The proper dose of medications will then be administered orally. You and your child will relax in our sedation waiting room. Within a few minutes you will notice your child becoming very relaxed. Your child will have slurred speech and will not be able to walk without your assistance. It is important for you to watch your child closely.

2) During dental treatment: Within about 30 minutes, your child will be taken by an assistant to the dental operatory. Once in the treatment room, nitrous oxide and oxygen will then be placed on your child’s nose to help your child relax prior to local anesthetic administration. A tooth pillow (rubber mouth prop) will be used to help your child keep his or her mouth open. Monitoring equipment (pulse oximeter) is used to ensure your child’s well being. If a parent choses not to be present in the dental operatory during the sedation procedure, an assistant will provide periodic updates regarding your child’s progress. The treatment time varies from 45 to 90 minutes.

3) Getting home: When your child’s treatment is complete, an assistant will reunite you with your child. During the recovery period, the doctor will provide a review of the day’s procedures and discuss questions or concerns that you may have. Your child will be dismissed when standard discharge criteria are met, anywhere from 15 minutes to an hour following the procedure.

After the Appointment

1) Constant Supervision: The effects of the sedative medication will dissipate quickly, however a “hang over” effect will last for several hours. Your child may initially be irritable. This is a drug effect called emergence delirium. The best way to get through this is to hold your child and try to keep him as quiet and relaxed as possible. Do not allow your child to walk unassisted until his balance is regained. Also, do not allow your child to bite or rub his cheeks, gums, lips, or tongue until about two hours after the appointment. Young children do not like the numb feeling from the local anesthetic and will need your help to prevent “lip biting.” Most children will take a long nap or may quickly fall asleep on the way home. Please know that more than 80% of the sedative medication is out of your child’s system before you are sent home. Sleeping is a “hang over” effect, not a drug effect. During this time it is important to keep your child’s head extended, do not allow him to snore, and protect against choking should your child vomit.

2) Drinking or Eating: You should encourage your child to drink clear liquids. Small amounts of water taken repeatedly help prevent nausea and dehydration. Soft, bland food may then be eaten, but only after the local anesthesia wears off. Soup and toast may be a good choice. Dairy products may cause nausea or vomiting so please refrain from dairy products until other foods have been eaten. If your child has trouble with vomiting, continue with small amounts of clear liquids until he or she is feeling better.

3) Fever and Pain: It is not unusual for your child to have a temperature of up to 100° for the first 24 hours after treatment. Children’s Advil® or Motrin® (both ibuprofen products) should be given as directed to help with fever and any oral discomfort. Use as directed on the bottle, based on your child’s weight.

4) Problems: The doctor is available at all times and should be contacted if one of the following occurs…

• Vomiting that persists beyond four hours after the appointment.
• A fever that goes above 101° or lasts longer than 24 hours.
• Any difficulty breathing.
• Oral bleeding that seems excessive.

If you have any concerns or questions please call our office.

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