Premedication in Pedodontics Attitudes and Agents
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PEDIATRICDENTISTRY/Copyright ~) 1979 by The American Academyof Pedodontics/ Vol. 1, No. 4 / Printed in U.S.A. Premedication in Pedodontics Attitudes and Agents David L. King, D.D.S., Ph.D. William C. Berlocher, D.D.S. Abstract a dentist should find it necessary to resort to premed- icating children to obtain their cooperation. Garfin The goals of premedicationin children’s dentistry are to feels that the routine use of sedatives and tranquiliz- allay excessive apprehensionand to prevent resistance to treatment efforts. With judicious use, premedicatingagents ers may rbflect a "decreased interest in the care and are a valuable and necessary adjunct for the pedodontis~. treatment of the complete child," and Olsen proposes Whenintegrated with proper psychological approaches, that dentists examine their motives to see if they em- premedicationmay enable the anxious child to accept his ploy premedication as a "crutch." Both of these au- first dental experiences without undueemotional turmoil thors emphasize that when faced with a potential or it mayoften allow outpatient treatment of very young management problem, proper psychological ap- "precooperative" children wherethe only alternative might proaches by the dentist will obviate the need for drugs be hospitalization and general anesthesia. Prudent employ- in most instances. MacGregorbelieves the dentist who ment of drugs [or behavior managementis dependent on resorts to premedication or general anesthesia may the training, experience, and iudgementof the operator. actually be treating his own fears and admitting his A regimen of premedicant drugs and dosages is presented inability to manage children. which may serve as base line guidance [or more successful 7 managementof the difficult child patient. In a similar vein, Chambers, a psychologist, decries dentists’ use of premedication in children because it Literature Review eliminates the possibility of the child’s learning to manage his anxiety. Instead, the child is introduced Premedication, Pros and Cons to an unhealthy method of coping with a difficult ,Jones 1 places dentists into one of three categories situation in much the same manner that a drug addict with respect to the views they hold on premedication: or alcoholic learns to react. He also feels physical re- straint is preferred to premedication because it has 1. Those who use premedication rarely and only in potentially less damaging consequences to the child. exceptional cases. However, Fisher, 8 another psychologist, regards any 2. Those whofavor routine use in all patients. use of force by the dentist as an approach which is al- 3. Those who find premedication valuable in behav- ways contraindicated. ior problems. There are a number of authors who are proponents Two recent surveys of pedodontists have indicated of routine premedication for children. Stewart9 feels that approximately 85% use behavior modifying drugs this approach is iustified and necessary because "In with3 some frequency, and that about 15% never do.2, children experiencing perhaps their first dental visit, In both studies, questionnaire design did not exclude apprehension may be acute and damaging." He also the possible use of nitrous oxide-oxygen by those who states that emotional stress on the operator will be re- reported they never use drugs. It is not unlikely that duced. some dentists in this category have found nitrous ox- Kracke1° advocates the routine use of heavy com- ide an effective substitute for drug premedication. bination premedication in order that a child’s total Garfin, 40lsen,5 and MacGregor6 have presented dental treatment may be accomplished in one visit. opinions which suggest there are few occasions when He believes that this practice avoids the multiple emo- tional upsets and peiorative behavior which can re- Accepted August 6, 1979 sult from a series of appointments. PEDIATRICDENTISTRY Vol. 1, No. 4 251 Corbett 11 has pointed out that under the best of nitrous oxide sedation, the reasoning being that the conditions, dentistry is not inherently pleasant for the child must be perceptually aware to fully benefit patient and that it is incumbent upon the practitioner fromz3 the learning potential of the situation.7, to use all the aids at his disposal, including premedi- Hawes~4 disagrees with this concept and comments cation, to allay the physical and emotional discomfort that it is doubtful whether an apprehensive child who of the patient. He believes -that the advantages of should have had premedication learns anything of premedication should not be reserved solely for the value while treatment is being performed. handicapped or recalcitrant child, but should be ap- Levitas ~5 and Chambers7 have implied that pre- plied to ease the first dental experiences of the nor- medication is at best a temporary solution to anxiety mal child as well. -that it only serves to postpone the inevitable con- Lampshire1-° classifies the behavior of child patients frontation the patient will have with his fears about in a spectrum from tense cooperative to hyperemotive dentistry when premedication is stopped. But Lamp- and maintains that premedication can be of benefit to shire26, 27 has found it unusual to have to continue pre- all. Dudley13 concurs, implying that overt resistance medication for more than three or four successive ap- by the child to treatment is not the only indication for pointments and notes that the dosage may be reduced premedication. He reasons that the outwardly coop- with each visit. Therefore, he considers premedication erative but emotionally anxious child who leaves the as an aid in establishing confidence and security in a appointment wet with perspiration deserves equal fearful patient after which it is no longer needed. consideration. Shapiro14 has recognized this type of Album, Davies, and Gelmon,28 and Chambiras-~9 also child, saying "The absence of crying or opposition characterize premedication as a temporary adjunct mean little . there are manychildren who react to and not an indefinite substitute for proper psychologi- threatening situations by becoming mute and pas- cal adjustment. They feel it can be used to enhance sive," and further that "this type of child mayundergo and reinforce the dentist’s initial attempts at rapport a severe neurotic storm a day or two later." with a difficult patient and that the dentist who ex- In addition to those proponents of premedication pends the effort to become skillfull at premedication already mentioned, several others also have defended is less likely to avoid treatment of children. their rationale by warning of the adverse psychologi- cal consequences a dental experience might hold for Premedicating Agents the emotionally labile child. Lang, in Album,16 Most authors seem to agree that inappropriate be- Ruble,lr and Kope118support the concept that a child havior on the part of the child patient is usually the may suffer "psychic trauma" with lasting conse- overt manifestation of an anxiety state. Depending quences as a result of anxiety about dental treatment. on the degree of anxiety and the child’s ability to Lewis19 assumes no position on the value of premedi- cope with it, this behavior may .range in a spectrum cation but believes that subjective fears of dental pro- from reluctant cooperation to violent physical resis- cedures may arouse castration anxiety in boys or be tance. Successful premedication aims at controlling or experienced as a form of sexual assault in girls. Crox- diminishing anxiety, thereby effecting behavior which ten, 20 however, refutes the idea that the dental exper- will facilitate treatment procedures. 17 That premedi- ience has the potential of being a psychologically cation is as muchan art as a science is reflected by traumatic experience for the child and points out that the many different drugs or combinations of drugs this essentially Freudian concept is neither substanti- which have been proposed by various authors. In gen- ated by research nor widely supported by psycholo- eral though, most commonly used agents may be gists. Edelston21 also flatly denies that serious or long grouped within the broad pharmaceutical categories lasting psychological effects can arise from an unfa- of hypnotics, anti-anxiety agents, and narcotics. vorable dental experience, even in a fundamentally The hypnotic class of drugs, when used in appro- anxious or insecure child. priate dosages, produces sedative effects through a McDermott,~’2 a psychiatrist, states that for the depressant action on the sensory cortex. For example, young child, the dental appointment "has far reaching chloral hydrate and the short acting barbiturates, sec- implications for personality growth." He abjures the obarbital and pentobarbital are employed quite often experience "which has been made as non-threatening for premedication in dentistry. Harris 3° believes the and "painless’ as possible, an emotionally sterile ex- barbiturates in particular are valuable for this pur- perience which does not harm, but neither does it pose noting that they sedate quickly with a high fre- promote personality development." Thus, he views quency of success and a very low frequency of un- dentistry for the child as providing an opportunity for desirable effects. Anderson31 has found chloral hy- emotional maturation. Others have used this concept drate to be an effective and safe premedicant when as an argument against use of drug premedication or used in larger dosages. Robbins~2 reports success us- PRENtEDICATION AI-rlTUDES AND AGENTS 252 King and Bet|ocher ing it either alone or in combination with prometha- duction of a certain amount of amnesia. ~ In accom- zine. He mentions that chloral hydrate has acquired plishing this sedation, diazepam has little effect on an undeservedly bad reputation from its use as a com- blood34 pressure and respiration. ponent of "knockout drops" and also from erroneous Promethazine, although not classified as an anti- reports that it was a circulatory depressant. His clin- anxiety drug, has been characterized by Sadove and ical study involved children whose ages ranged from Fryez~ as producing a state of quiescence with little 22 months to six years.