PEDIATRIC DENTISTRY/Copyright © 1982 by The American Academy of Pedodontics Volume 4, Special Issue 1

Alphaprodine-dimenhydrinate sedation in Dr. Dixon pedodontics Howard R. Dixon, DOS, MS

J. have practiced in San Diego for eleven years and A perplexing problem that faces the pedodontist for the past five years have practiced with both a is the operative managment of the young preschool pedodontic and orthodontic associate. We have an aged dental patient. Many children approach the den- eleven-chair office, two of which are located in tal experience with a normal but controlled amount separate rooms and set up for use in sedation cases. of anxiety. Some children, for various reasons, are My primary use of the alphaprodine-di- not able to cope with the dental situation. Patients menhydrinate (Dramamine®) sedation technique is as in that category, be it due to physical, emotional or a substitute for taking the young, nonmedically com- mental handicaps, or because of young age, offer a promised, child patient to the hospital. I average four challenge to the practitioner who desires to treat the to five sedation cases per month and my associate child in the office. The nonpharmacotherapeutic ap- averages eight to nine sedation cases. I utilize this proach to behavior management is the most desirous sedation technique primarily for the young nursing form. With the potentially cooperative child this ap- caries case. It is also helpful in treating cases of oral- proach may start with the psychological approach; dental trauma in the very young child. techniques of tell-show-do, modeling, reinforcement, My treamtent of nursing caries cases are com- or association. Many children will respond to these prehensive. I make every effort to save the anterior approaches and will not require special measures of teeth and opt to perform pulpectomies and plastic control. crowns instead of extractions, unless the case In some instances, the behavior management of the definitely dictates extraction. The child is typically child patient will not be controlled by psychological between 18 and 30 months old. I have found that the methods and must be supplemented with the phar- use of alphaprodine-dimenhydrinate is an excellent macotherapeutic approach. Sedation should be way of treating these children without resorting to viewed as an aid in helping the child cope with the hospitalization for their care. dental situation by reducing anxieties and raising the I have used alphaprodine for around eight years pain threshold. and the combination of alphaprodine and The sedation technique may start with the use of dimenhydrinate for about five years. Over that period nitrous oxide/oxygen relative analgesia. Along with of time, we have utilized alphaprodine for approx- this inhalation approach, one may also incorporate imately 500 cases. This is not a large sample, but I the use of oral, parenteral, rectal, or combinations of feel it is an adequate sample as far as clinical ex- the above drugs. Should the sedative and psycho- perience is concerned. logical techniques prove to be inadequate in the The restorative treatment in the very young or the behavior management of the child, the practitioner unmanageable preschool child is a common problem must weigh the decision to use general anesthesia or for the pedodontist. Several drugs have been used for accept compromised treatment. years in pedodontics with varying degrees of success. Inhalation analgesia has afforded the pedodontist For me, the use of an alphaprodine-dimenhydrinate a modality to help control many apprehensive and combination in conjunction with nitrous oxide/ anxious dental patients. Its advantages are that it oxygen has been a highly successful technique in the allows for accurate titration of effect, atraumatic ad- management of very young, nonmedically com- ministration, rapid induction and recovery, and a promised patients where hospitalization and general minimum of contraindications. Its disadvantages are anesthesia may have been considered as the alter- the increased incidence of nausea, refusal of the native method of patient management control. mask, and mouth breathing with the result of inef-

PEDIATRIC DENTISTRY: Volume 4, Special Issue 1 195 fective sedation. problems of continued mouth breathing and the in- The pedodontisi; must be cognizant of the limits ability to gain adequate sedation with the excited of nitrous oxide/oxygenanalgesia and its inability to young patient led me to supplement the relative control all forms of behavior problems, especially of analgesia method. The advantage of the parenter- the defiant or hysterical variety. The philosophical ally administered drug appealed to me after dis- approach toward pharmacology for each pedodontist appointing success with oral premedications. should be to limit the numberof drugs used: in this The use of alphaprodine was considered because it way the characteristics of those drugs which are is a rapid acting narcotic of short duration. The used can be predictably known and the chances of primary advantage of alphaprodine is its fast onset successful sedation increased. of action. Whenadministered submucosally its onset of action is usually apparent within five to ten minutes. It is rapidly metabolized by the liver with The pedodon fist must be congnizan t of little unchanged drug being excreted in the urine. the limits of nitrous oxide~oxygen Respiratory depression is the most undesirable side analgesia and its inabih’ty to control a11 effects and can be life threatening. A narcotic an- tagonist such as the naloxone must be available with forms of behavior problems... a syringe for immediate use if signs of respiratory depression are observed. In addition to the potential for respiratory depres- Oral sedative drugs have been used for years in sion, the most commonundesirable side effect is pedodontics with varying degrees of success. It is a nausea and vomiting. The reaction tends to occur very popular met:hod of administration due to the more often at the end of the treatment procedure and relative ease of administration and the potential usually not until the patient is in the upright posi- calmingeffects to the child before arrival in the of- tion. This undesirable side effect of narcotics has led rice. Relative analgesia can be a successful adjunct many practitioners to use promethazine as a co- to this approach. The disadvantages of oral medicant to counteract the emetic potential of the premedication are the undependable absorption fac- narcotic. tors, possible poor parental cooperation, and The possible potentiating effect of promethazine paradoxical excitement reactions in some children. when utilized with a narcotic like alphaprodine Occasionally a child’s behavior can not be con- became a concern of mine. I found dimenhydrinate trolled by the use of oral and inhalation routes of ad- to be comparable with alphaprodine, and to have a ministration and the pedodontist may choose to sup- low potentiating effect on the narcotic. A dosage level plement them with parenteral drugs. The parenteral of 0.725 mg/kg 10.33 mg/lbl of dimenhydrinate in- route maybe utilized with one or both of the oral and jected submucosally was found to successfully con- inhalation methodsand offers the practitioner a more trol the narcotic-induced nausea. This technique is dependableeffect due to the greater certainty of ab- utilized mainly on the unmanageablechild between sorption of an accurate knownquantity. The method 15 months and 5 years of age. of administration can be subcutaneous, submucosal, The child’s medical history should be evaluated: or intravenous. The intravenous route is not often this technique should be used with extreme caution indicated in the very uncooperative child in the of- in patients with hepatic insufficiency, severe CNS rice becausethe probability of side effects is increased depression, convulsive disorders, and allergic or any {the severity and speed with whichthey occur are also other systemic conditions affecting respiratory func- factors to consider}. tion on airway maintenance. The object of this paper is to introduce the use of Hospitalization with general anesthesia should be the parenteral administration of alphaprodine- considered if the child is unmanageablewith other dimenhydrinate in combination with nitrous oxide/ methodsand/or if the medical history indicates that oxygenas a reliable technique for controlling the un- the child may be compromised if the narcotic is manageableyoung pedodontic patient. It is utilized utilized. as a technique to manage the young, nonmedically Whena child is considered for the alphaprodine- compromised patient where hospitalization and dimenhydrinate regimen, parents are given instruc- general anesthesia may have been considered as an tions to have the child NPOfor four to six hours alternative method of patient managementcontrol. before the administration of the drugs. It has been I started utilizing alphaprodine approximately found that postoperative nausea and vomiting can eight years ago as an adjunct to nitrous/oxygen be successfully controlled with the use of analgesia whenI realized the limitations of the use dimenhydrinate and by having the child NPO. of inhalation analgesia in the youngchild patient. The Postoperative nausea and vomiting has been oh-

196 ALPHAPRODINE-DIMENHYDRINATESEDATION: Dixon served only if the parents have violated the NPOrule. use of Citanest, I feel that I use a very low dose and The dosage of alphaprodine found to be successful therefore am not at a level of danger. in managingthe child patient whoqualified for this After operative local anesthesia is achieved and the technique was in the range of 0.66-1.1 mg/kg{.3 to child is in an acceptablysedated state, the restorative .5 milligrams per pound}. The average dose that I treatment can be initiated and the nitrous oxide/ have utilized is around .88 mg/kg{.4 milligrams per oxygen level reduced to somewherearound 35-40%. pound}. This dose varies with the child’s observed Most of mycases last about an hour, but an hour and behavior and temperament during the initial ex- a half is possible. The child’s respiration is monitoredwith an inhala- tion anesthesia machine that I utilize. I have what The child’s respiration is monitored with is called a Bird Corporation Blender®. It has a de- an inhalation machine.., winch has a de- mand feature which has an audible sound. The in- mand feature with an audible sound to it. troduction of gases into the bag causes this audible sound. It is a definite hissing noise. As the gases comein, the valve opens and closes so you can hear the respiration of the child as you are continuing with amination appointment and at the start of the treatment. In addition, the child is constantly ob- operative appointment. The dose is calibrated after served visually during the procedure. The rubber dam the child has been weighed, and the medication is ad- is utilized whenevernecessary. ministered with a 26 gauge 3/8 inch needle and a At the end of the procedure, 100%oxygen is ad- tuberculin syringe. ministered for at least five minutes to fully oxygenate Whenthe child is brought into the operatory, he the child. is placed on a papooseboard without restraints. The Althoughit is rare that I have to schedule a second child’s behavior is then observed during the induc- appointment to complete treatment, I’m not uncom- tion of nitrous oxide/oxygen. The patient is started fortable with that if it is necessary. I break it up on 40-50%nitrous oxide, depending on the behavior into one arch at one appointment and another arch exhibited. The usual level being around 45%. the next appointment. Restraints are applied for the administration of the I have emergencyequipment available if it is re- drugs and for use during the operative procedure if quired. The assistant and/or a doctor is always with it is deemednecessary because of negativebehavior. the patient. I have to report that there has been If the nitrous oxide/oxygen alone is unsuccessful only one child in the eight years that I have been in controlling the patient, the drugs are drawn and using alphaprodine that experienced any respiratory injected into the submucosaltissue in the maxillary depression or cyanosis, and this child was treated im- tuberosity region. The practitioner must aspirate mediately with naloxone~ and reversed successfully before any submucosal injection to reduce the with 0.2 milligrams. I had this reaction with pro- possibility of intravascular injections. methazine and I have to agree with some of the in- There were times when I have injected the drugs formation that Dr. Creedon has related to you con- in the retromolar area where we would give a man- cerning his experiences with promethazine and dibular block injection, but I found that because of alphaprodine. Therefore, I do not recommendthe the anesthetic effect of the alphaprodine, I had some combination of those two drugs. That was only one children that would chew their lip and or tongue; experience but such experiences tend to be very therefore, I have tried to avoid that location for vivid. injection. I view the efficacy of this combination of After signs of sedation are observed, the local alphprodine and dimenhydrimate as very good. I anesthetic Citanest Forte is given, because of its would say that mysuccess in sedating children is in short duration and the increased depth of anesthesia the 90%plus range. I am very comfortable with the achieved. Local anesthesia may be limited to the use of these drugs, and am very happy with what I anterior teeth and the amount kept to a minimum. amable to do with them. I wouldfind it very difficult The usual amount is approximately half of a 1.8 cc to continue the type of office-based care that I desire carpule, and more than one carpule has not been re- to provide for children without them. quired in any of mycases. Dr. Dixon is in private practice of pediatric dentistry, 4690 Genesee Although Dr. Aubuchon has mentioned the in- Avenue, San Diego, CA 92117. Requests for reprints should be creased possibility of convulsive reactions with the sent to him.

PEDIATRICDENTISTRY: Volume 4, Special Issue 1 197