IV Sedation for Dental Work in young child - opinions? negative side effects? are the drugs safe? - Mothering Forums

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#1 of 22 Old 01-06-2014, 04:28 PM - Thread Starter
 
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My preschooler chipped his front tooth and because of his age and temperament the dentist has recommended IV sedation while she works on him. (Not doing anything is not an option; I doubt I could hold him still and force him to keep his mouth open if not sedated.) She has a doctor who is board certified in both pediatrics and pediatric anesthesiology come in to do the work in the dentist's office. This doctor has been doing this for over 15 years at many different dental offices and has never had a situation in which a child had to be transported to a hospital. I've been in contact with the doctor/anesthesiologist about the drugs used for sedation, and she told me that she starts with Midazolam (Versed) and Ketamine (either in the IV or in a pre-IV shot, depending upon the kid's behavior), and then follows that with Robinal and Propofol. If need be she also uses Nubain and Brevital. 


I've looked into these drugs and from what I can gather Midazolam (Versed) serves as a sedative, hypnotic, muscle relaxant, and creates amnesia. It also has been linked with some nasty negative reactions.

Ketamine induces anesthesia, is an analgesic, and is hallucinogenic (for better or for worse).
Robinal reduces various bodily secretions, including saliva.
Propofol induces and maintains anesthesia.
Nubain provides pain relief (if I'm not mistaken it's the one of the pain relievers they'll give you in labor if you are not too fully dilated).
Brevital induces anesthesia.


I'm nervous about the whole procedure of course, but the drug I'm most nervous about is Versed, as a portion of the population evidently reacts poorly to it. When I asked the anesthesiologist specifically about it she said that while it can have unpleasant adverse reactions in some people, she doesn't see them since it is used with other drugs. She suggested that perhaps they are there but are covered up by the deep sedation so it is not a problem.  


So, opinions from other folks out there - have you used IV sedation? Were those the drugs used (if you know)? Did it go ok? Would you allow the specific drugs above to be used on your kid? Why or why not? Know of any good alternatives? Have I correctly listed why they are used?


Thanks for any help you can provide!

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#2 of 22 Old 01-06-2014, 06:02 PM
 
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I, personally, have had most, if not all, those drugs. I have had 10 or 11 surgeries in my lifetime. All but two were under general anesthesia. I love versed! It is a very relaxing drug. It does its job very well. The youngest I ever had anesthesia was at age 8. It was general anesthesia. Everything turned out fine. I have never had any reactions to anything. It's good to know that a pediatric anesthesiologist will be there. You want to make sure that your child will be continuously monitored throughout the procedure and at all times while going under and coming out of any of the anesthesia drugs... by the anesthesiologist. If it were me, I'd also like to know what the protocol is for any emergencies, if they arise. I had one dental surgery, wisdom teeth extraction. That was done in the hospital. That was my personal preference. I was 20 at the time. Is your dentist office in a stand alone building? If so, is it around the corner from the hospital? Or, is the dental surgery taking place in an outpatient surgical center or hospital? Just curious. My main concern wouldn't be about the drugs, but more, what is the emergency protocol and how close will you be to a hospital setting if necessary. I would be perfectly ok with these drugs being administered to my children... by a board-certified pediatric anesthesiologist. I would not be ok with a dentist doing any sedation AT ALL. That's just me. Novocaine for a minor filling, no biggie. But any sedation needs to be administered by an appropriate person, that being a pediatric anesthesiologist. Sounds like that is the case here.


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#3 of 22 Old 01-06-2014, 06:43 PM
 
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My son had Midazolam and propofol for an MRI when he was 13 mon and it worked very well.  They tried to put an IV catheter in without sedation and it was horrible baby torture:(.  They gave him midazolam and he was super happy while they put the IV in.  He didn't even notice and kept giving me kisses :love.  He woke from the propofol very smoothly. 

 

My son then had some dental work done at two and my daughter at 4 (not the same day).  They both had a gas anesthetic administered via mask, then got their IV's put in for propofol.  They both freaked out when they woke, like they were having a nightmare.  But neither of them remembered the freak out part later.  I was told it was normal for young children.  I'm not sure if it was the gas or the propofol that caused their reactions, but my son had no such reaction with just midazolam and propofol at 13 mon. While their recovery was difficult for me to watch, they didn't remember it later and I think getting a needle without gas first would have been more traumatic for them, especially for my 4 yo.  The only problem they had after going home was my son had a bit of a sore throat for a couple of hours from the tube that was put in for oxygen while he was asleep. 

 

Will there be oxygen on hand at the dentist office and will it be given?  I'd feel better if it were at least on hand if needed. 

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#4 of 22 Old 01-06-2014, 07:01 PM
 
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We had sedation done for one of our children in an outpatient surgical unit. It went fine with no complications. There is absolutely no way I would have allowed this in a dentist office. There have been numerous articles coming out lately on the dangers of dental sedation in children, including a 3 year old who died last Friday in Hawaii. If your dentist is not willing to go to an appropriate facility I would find a new one.

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#5 of 22 Old 01-07-2014, 01:41 PM
 
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Personally? No.  First of all at preschool age we're talking non-permanent teeth, correct?  So why bother - it's just temporary.  My first experience with gas was at age 4 and I scared the staff because I was a little too happy.  They calculated dosage for my age/weight but no one knew I had a poor metabolism for meds (heck, didn't find that out til I was 30) and even scaling me back, I took a while to recover.  At 16 had my wisdom teeth out at an outpatient surgical facility, gas and IV - almost didn't wake up and had partial facial paralysis for almost 48hrs following.  The problem with reactions is you just don't know who will react poorly until it happens and it's not a chance I'd personally take with my DD unless it was life or death, not just cosmetic.

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#6 of 22 Old 01-07-2014, 02:01 PM
 
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I'm with Sassyfirechick. I would not risk sedation for a non-permanent tooth. Is it painful to your child? Why are they wanting to work on it rather than just wait for it to fall out?

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#7 of 22 Old 01-07-2014, 02:03 PM
 
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I just want to chime in that dental problems are not just a cosmetic problem. Left untreated, they can be very painful and affect overall health. Obviously prevention is best, but not always possible in the case of an injury.
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#8 of 22 Old 01-07-2014, 02:15 PM
 
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That's why I'm curious why the doc wants to fix the tooth. Is there pain involved? I'm asking because it is a significant risk.

Recently, I noticed my son had a grey tooth! I was totally freaked out. Apparently he had injured the tooth but I have no idea when. I called the dentists office and immediately they told me he needed X-rays, etc. and started talking about a baby root canal!!! I ended up going to the naturopath. He checked it for abscess and said to just watch it. It's starting to lighten up now.

It sounds like the OP is trying to weigh her risks so I was trying to get more info.

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#9 of 22 Old 01-07-2014, 02:44 PM
 
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Gotcha. I submitted before Seeing your post, Dalia and my comment was more in reresponse to Sassy's who seemed to be assuming the OP's reasons for treating were purely cosmetic.
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#10 of 22 Old 01-07-2014, 03:44 PM - Thread Starter
 
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OP here - just had the chance to see responses - we lost power last night with the storm - ugh! Will reply more specifically to all comments in another message, but for now ...

 

Thanks for the responses! I understand the concern about having work done in the dentist’s office rather than as an outpatient at a hospital, and I’m also still trying to decide how to deal with that issue. Since the anesthesiologist my dentist uses does the work in the dentist’s office, the very first thing I asked about was her track record and how prepared she was to handle emergencies. She says that she has done over 6000 in office sedations and has never had to transport a child to the hospital, although they are prepared for that if an emergency happened. She’s both a board certified pediatrician and a board certified pediatric anesthesiologist and she brings a team of people with her, one of whom also works as a paramedic and Care Flight nurse for one of the local hospitals. She also brings an assortment of drugs and equipment with her in case something happened (I had asked specifically about whether she could intubate there in office if necessary and said she brought laryngoscopes, ETT tubes, LMAs). She also noted that in none of the recent cases involving tragedies in dental offices were there pediatric anesthesiologists present. (I know that is true for the Hawaii case – my understanding is that the dentist or a dental tech administered oral sedatives, they left her unattended for close to a half hour, and then they had to go hunting for a pediatrician because they didn’t know how to resuscitate her.) The pediatric anesthesiologist’s main argument is that this is perfectly safe and that she is as fully trained as anyone can be who deals with sedation. She also noted that the Society of Ambulatory Anesthesiologists has collected data over the past 8 years that proves that if office sedations are conducted by physician anesthesiologists and following the published guidelines that they are very safe.

 

My dentist also has privileges at a local hospital, so I could request to have the work done as an outpatient there, but I think it would be under general anesthesia rather than IV sedation (difference between the two as they use the terms being that with IV sedation the kid is out but breathing on his/her own, and with general the kid is out and intubated). My insurance won’t cover the hospital costs (long story there), but I don’t want price to come in the way of safety. Others I have spoken with argue that the hospital experience could be more traumatic to the child than the dentist office because the dentist office is more familiar. No clue if that is true or not.

 

Anyway, so if anyone has made it to the end of this long post and has any other thoughts on the topic – safety, where to have it done, drugs to use, etc, please chime in!

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#11 of 22 Old 01-07-2014, 04:05 PM - Thread Starter
 
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Ok, one more from me - I completely agree that if the issue is just cosmetic, don’t risk anything. However, from what I can gather from the dentist, this is not just cosmetic. According to her, the reason the tooth cracked so readily was because there was a cavity forming between the front teeth that weakened the tooth’s structure. I hadn’t noticed an issue before it was cracked, but then again I’m not trained as a dentist. (Dentist suggested that night nursing might be to blame. My son demanded at least one night-time feeding up until he was past 2. He’s 34 mo old now and still sleeps horribly but doesn’t demand any milk. If I had to do it all over again, I’d still do it the same – I’d have no sanity left now if I hadn’t.)  She also said she saw several cavities forming on the back molars and recommended that we go ahead and seal his other molars, even though insurance won’t cover it, since it looked like his teeth might be easily susceptible to decay. I’m the type who is skeptical about everything, especially dentists, but I’ve always had issues with my teeth, regardless of how often I floss and brush, and I’m afraid he might have inherited that issue from me. I have horrible memories of having baby teeth filled (even though my siblings, with identical dental hygiene practices, had no fillings) and I really would rather not put him through that if I can catch these issues before they become big.  I do understand the argument to wait and see since these are just baby teeth, but as CuddleBug’sMama noted, when left untreated even baby teeth can become very painful and create health problems. The 3 yo son of a friend of the family had an abscessed molar – not a pleasant time for anyone.

 

Dalia, although I personally haven’t dealt with this, I do know others who have gone through the “ack, it’s a grey front tooth!” issue. Their dentist described it as being something like a bruise, and adopted a wait and see approach to see if it cleared up (in their case it did). They were told that sometimes it will clear up, but sometimes it won’t and if that happens it often means there is a deeper issue, perhaps infection. It’s too bad that your dentist was so quick to suggest treatment – I know not all dentists are like that.

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Teeth sealing is an iffy thing for me.  I've got pretty near perfect teeth in terms of health - never a cavity, no soft spots, no discoloration - yet as a kid the dentist still convinced my mother I needed all my molars sealed and they pushed big time for bi-yearly xrays...so yes I am a dental skeptic!  I'd certainly go the route of an ND like dalia and/or utilize essential oils for discomfort before surgery.  Then again it may also be because my aunt has had more dental surgeries than I can count, many of them being to repair what others have screwed up and I'd never want me or my child to go through that.  She hasn't even been to a dentist yet and she's 26mos ;)  And I'd likely chuck something at any dentist who blamed night nursing as a cause of teeth issues because there's not much proof on that front.  Mine is up a least once a night to nurse!

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#13 of 22 Old 01-07-2014, 07:02 PM
 
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I live in the PNW and there are naturopathic dentists up here... I wonder if this is something you would consider, OP? Or maybe getting a second opinion?

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#14 of 22 Old 01-09-2014, 10:17 PM - Thread Starter
 
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Catching up on posts again -  

We're not in the PNW, and I'm not aware of naturopathic dentists in our area. I have nothing against the idea of them, just not too sure if any are around!

 

We did get a second opinion from another pediatric dentist in the area. Not an easy task, as getting my LO to keep his mouth open for a dentist to look into it involves me holding him on my lap and keeping one arm still, a dental tech holding his other arm to keep it still, and him screaming bloody murder, which, although noisy, does mean his mouth is open! Anyway, that dentist concurred that the front teeth should be fixed, but she does not use sedation at all. She relies on what she calls a papoose, which to me seems like a straightjacket attached to a board that physically pins the kid down and keeps him still. She also does not allow parents back in the exam room while she's working. Seeing how upset my son gets just at having someone look in his mouth, I can't in good conscience agree to have him strapped into a straightjacket - that would seem like cruel and unusual punishment to him.

 

So, it really seems like sedation might be best for him, but question is which drugs (because if I'm not mistaken versed is not absolutely necessary) and where and which type (IV sedation in office or general anesthesia in hospital). Who knew getting teeth fixed could be this complicated?  

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#15 of 22 Old 01-10-2014, 09:00 AM
 
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http://www.cbsnews.com/news/nj-dentist-investigated-after-2nd-childs-death/

 

It could have been the combo of the papoose/sedation, but I agree with you that strapping a child down like that could be far more traumatic.  I know there are practices around me that do non-sedation dentistry with things like aromatherapy, hypnosis, relaxation breathing, but not sure how much of that is geared towards kids or just adults.  On to the drug options - how likely is this person to actually work with you on that level and not include the drugs that you feel have higher risks strictly because she personally doesn't see them occur?  That would bother me a bit, where she mentioned she'd not seen reactions but thought perhaps it was the combination of drugs that masked the underlying reactions.  I guess the idea of a hidden drug reaction is even more scary because in the god awful case something does go wrong, it just seems like an easy out for the drug companies because it would be a hard time pinpointing an exact cause, KWIM?  I guess I'd want to look long and hard at the numbers and have some pre-anesthesia blood work done to narrow down potential risk factors before coming to a decision, and really I'd think the person in charge of the anesthesia would also want to know this.  As an example of "who'd have ever known" scenario - I had some DNA testing done for another issue and what came back was pretty surprising and I'd think very important to know - I have a high sensitivity to blood thinners, particularly Coumadin, and not that I've ever needed them, but they can be pretty common in various conditions and theoretically, the "standard" dose for someone like me would be too excessive and could be lethal.  I would have never known this.  So I'd ask what sort of pre-screening they do to determine potential for reactivity in individuals rather than relying on data from groups since every person has a potential to react differently.

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#16 of 22 Old 01-10-2014, 09:07 AM
 
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Oh, that is another thing... I don't think we did blood work but we were required to take her to her physician and get clearance from him before they did it.

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#17 of 22 Old 01-15-2014, 06:16 PM - Thread Starter
 
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Sorry for being so slow in posting this, but THANK YOU ALL!!! once again for your thoughtful posts. You've given me lots to think about and consider. I've been talking with the dentist and anesthesiologist some more to try to figure out what is my best for my son and try to get as much pre-screening done as possible to try to rule out some of the unexpecteds. Still haven't decided for sure what route we'll go, but, as I said, your responses gave me lots to think about and good questions to ask!

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#18 of 22 Old 02-08-2014, 11:42 AM
 
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She relies on what she calls a papoose, which to me seems like a straightjacket attached to a board that physically pins the kid down and keeps him still. She also does not allow parents back in the exam room while she's working. Seeing how upset my son gets just at having someone look in his mouth, I can't in good conscience agree to have him strapped into a straightjacket - that would seem like cruel and unusual punishment to him.

 

 

 

Yeah, I would NEVER allow this to be done to my son. It breaks my heart to even think there are kids being strapped down torture-style without their parents there to comfort them like this. That's the kind of trauma that sticks with a person through life. IV sedation sounds far, far preferable. No contest! I understand your worries, but it really sounds like you're in good hands with someone who has an excellent track record.


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#19 of 22 Old 02-14-2014, 10:30 PM
 
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Yeah, I would NEVER allow this to be done to my son. It breaks my heart to even think there are kids being strapped down torture-style without their parents there to comfort them like this. That's the kind of trauma that sticks with a person through life. IV sedation sounds far, far preferable. No contest! I understand your worries, but it really sounds like you're in good hands with someone who has an excellent track record.

I agree.

If things go wrong with anesthesia, (IMO)doesn't matter so much where you are, but that you have the right people and tools. You could get this data if you wanted, I bet. If he reacted badly he needs treatment in seconds, and get transferred when he's more stable. It sounds like they are prepared, and that you've asked the right questions.

Another thought was, I don't know much about dental stuff, except that a) it's a big deal for general health and b) it can be controversial. So getting a 2nd opinion sounds good, but also coming from the same allopathic world view. I'm sure a naturopathic dentist would have alternatives.

You could have the anesthesiologist list alternatives to the versed, then compare side effects---- unfortunately I bet they all have similar stuff, but maybe not? But since versed it's what she usually uses, she probably knows it very well, which might make it the safer choice for her.

I think what the dentist is proposing sounds totally reasonable. And we can never totally know the exact right answer , sometimes until decades later. I think you should ask a lot, research a lot, but also trust their experience (if they have earned that).

My DD was sedated for about 1 week with fentanyl after her birth (at 27 weeks). A few months later she had eye surgery, which I'm sure involved versed or similar, but to me it wasn't an option to not do the surgery, and I trusted that the pediatric anesthesiologist knew more about pediatric anesthesiology than I did, so I didn't ask about it. But feeling certain about the surgery made it all easier. I personally got versed and propofol for a D&C which went very smoothly.
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#20 of 22 Old 02-15-2014, 08:39 PM
 
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For painless or minor work with a local I love that our dentists have had TV's at every chair and are very nice, patient, and gentle. My 4 year old had no trouble at all with molar fillings without even any nitrous to calm him. TV truly is like a drug, so glad we don't have it often at home! My first needed the papoose board for early dental work, better than sedation in my experience since I have always had bad reactions to even a little of anything that altered my alertness (valium, nitrous, phenergan, alcohol), causing me panic and disorientation, I think being knocked out and losing time and memory on waking would be worse to me. Others are fine with it I know. But he seems to take after me he has had nitrous in more recent visits and hated it, but loved to watch a movie during it.

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#21 of 22 Old 03-13-2014, 03:15 PM - Thread Starter
 
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OP here, just wanted to post an update in case somebody sees this discussion later and wonders what happened. (I know I always wonder with discussions like these!)

 

We went ahead and did the IV sedation in the dentist's office after a lot of deliberation. In the end we decided that the anesthesiologist had such a strong track record and so many years of working with children in exactly this setting that we probably were in as good of hands, if not better, than we would be in had we gone to the hospital and used the anesthesiologist there. It also didn't hurt that she was also a board-certified pediatrician. We also followed her suggestions for drugs, including Versed, because in the end we just had to trust that she knew what she was doing.

 

So how did DS handle it? Only negative was that he screamed for over an hour following the procedure. Why was he screaming? Based on what he told me and what he was doing, he was angry that he wasn't allowed to walk around on his own, and the few times he did escape my arms he then was even more angry when his attempt to bolt failed miserably with him falling over. (The after-effects of the drug made him act very much like he was drunk with absolutely no coordination.) Once the drugs wore off though, and his coordination returned, he was much better. I'm sure it was disconcerting to him to feel so loopy-headed, and I tried to explain to him why he felt the way he did, but I don't think that did much good!

 

And as for the teeth and his mouth? He never once complained about his mouth hurting; he only complained because the dentist had put this really sticky, tacky, fluoride mixture over his teeth which felt weird. Since he didn't need lidocaine shots to numb his mouth, he also didn't have to deal with the weird "mouth coming out of numbness" feeling, and I didn't need to worry about him inadvertently biting his cheeks or his tongue while he was numb.

 

So, in the end, I'd say it was a positive experience given the options we had. I think we were fortunate to be in an area with as experienced of an anesthesiologist as we had - I know other areas aren't as lucky, and I feel certain we would have made a different choice had the anesthesiologist been different. With any luck we'll never have to go through this again, though!

 

Thanks again for all of the suggestions, recounts of past experiences, etc. They really helped!

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#22 of 22 Old 03-13-2014, 06:35 PM
 
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Thanks for the update. Glad it went well.

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