Pediatric Dental Health

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Sedation Of Children For Dental Procedures
Most children are cooperative during dental treatment, despite occasional moments of anxiety. Nevertheless, some children, especially the very young and fearful, may have difficulty cooperating for treatment at the dental office, and may benefit from behavior management techniques. One pharmacologic behavior management technique is conscious sedation. During interactive conscious sedation, a child can respond to verbal requests from the dentist, and keep the eyes open while being sedated. Conscious sedation is often provided because it may be the only way to provide dental care for children whose insurance companies refuse to pay for dental treatment under general anesthesia. It is unfortunate that less than half of all states reimburse dentists for general anesthesia if the child has no underlying medical conditions.

Conscious sedation can be provided using specific drugs and delivery techniques. Some of the drugs used in pediatric conscious sedation include meperidine, chloral hydrate, midazolam, and ketamine. Certain drugs should only be administered via specific routes, such as the oral, I.V., rectal, or intramuscular routes.

The oral route is the oldest of all routes of drug administration, and still the most commonly used. It is a useful method for managing uncooperative or fearful children who need dental treatment. The oral route offers some advantages over other routes, including decreased incidence of adverse reactions, lower cost, and ease of administration. The disadvantages of the oral route include prolonged onset time, prolonged duration of action, and erratic absorption from the GI tract. Most orally administered drugs demonstrate the highest blood levels at approximately 60 minutes after ingestion. The absorption of a drug from the GI tract is affected by its lipid solubility, the pH of the gastric juice, slow gastric emptying time, inactivation of the drug by the liver, and drug bioavailability.

An adequate preoperative evaluation is an important part of the conscious sedation process.
Some of the major components of the evaluation include:

A thorough review of the child's medical history.
A review of systems. This means evaluating each of the child's functional systems, such as the: cardiopulmonary, airway, hematologic, central nervous, renal, hepatic, gastrointestinal, endocrine, and metabolic systems.
Knowledge of the child's current medications and allergies.
Knowledge of the child's previous sedation experiences.

Adequate monitoring during conscious sedation is essential to detect any developing complications. The clinician providing the sedation must be able to recognize and treat airway and other complications quickly and appropriately. A thorough knowledge of the pharmacology of the drugs being administered is vital. Emergency drugs and equipment must be immediately available at all times. Possible complications associated with conscious sedation include oxygen desaturation, vomiting, airway obstruction, apnea, laryngospasm, stridor, bronchospasm, cardiac arrest, or death.

A recent study published in Pediatrics investigated the causes of adverse events during pediatric sedation. According to the study, inadequate resuscitator skills were an important determinant of death and neurologic injury for nonhospital-based sedation procedures. The effects of the sedation medications on a child's respiration were also found to be important factors in morbidity and mortality. Some of the article's conclusions were that age and size-appropriate resuscitation drugs and equipment should be immediately available, irregardless of where the sedation takes place. In addition, clinicians who sedate children should be skilled in the resuscitation of sedated children.
Cote CJ, Notterman DA, Karl HW, Weinberg JA, McCloskey C: Adverse sedation events in pediatrics: a critical incident analysis of contributing factors. Pediatrics 2000 April; 105 (4) 805-814.

What Is A Mucocele?
A mucocele is a smooth, soft, mucus-filled enlargement which may appear on the lower lip of a child. It is usually the result of trauma, such as lip biting, which injures the tiny salivary ducts inside of the lip. Injury or rupture of these microscopic excretory ducts leads to an accumulation of mucus inside of the connective tissue of the lip. Mucoceles often swell and rupture periodically. Some mucoceles do resolve on their own, but most of them need to be evaluated and treated by a dentist. If a mucocele remains untreated, it may develop an irregular surface with a pink color, and may become a source of irritation for the child.

When examined under a microscope, mucoceles can be categorized as either mucus retention cysts, or as mucus extravasation cysts. Mucus retention cysts, when seen on the lip, are slightly blue in color, because of the thin layer of epithelium covering the bluish capillaries. Mucus extravasation cysts, which occur more frequently, take on the same color as the rest of the lip, since they are covered with a thicker layer of granulation tissue.

Mucoceles usually occur on the lower lip, but may also appear on the inside of the cheek, on the tongue, and on the palate. They are seen more frequently in females, and from the ages of 10 to 30.

Treatment options for mucoceles include surgical removal, creation of a pouch (marsupialization) inside of the lesion, freezing (cryosurgery), laser ablation, and micro-marsupialization. Treatment in children can be complicated by occasional behavior problems during treatment.

A new technique for treating mucoceles of the lip was described in the April issue of Pediatric Dentistry. This alternative treatment, called micro-marsupialization, requires neither injections nor surgery. Micro-marsupialization basically involves placing a topical anesthetic gel on the mucocele for 3 minutes, passing a 4-0 silk suture through the body of the mucocele, and trying a surgeon's knot. The suture material is removed 7 days later, at which time the mucocele is resolved. The advantages of this technique include simplicity and relative lack of pain. Micro-marsupialization is not indicated for fibrotic lesions, lesions of the palate, or for lesions inside of the cheek (cheek mucosa).
Delbem AC, Cunha RF, Vieira AE, Ribeiro LL: Treatment of mucus retention phenomena in children by the micro-marsupialization technique: case reports. Pediatric Dentistry. 22:155-158, 2000.

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