Cumhuriyet Dental Journal: 2018; 21(2) Doi: 10.7126/cumudj.400765 RESEARCH ARTICLES

RETROSPECTIVE EVALUATION OF TECHNIQUES FOR TOOTH EXTRACTION IN PEDIATRIC PATIENTS

Çocuk Hastalarda Diş Çekimi Amacıyla Uygulanan Sedasyon Tekniklerinin Geriye Dönük Değerlendirilmesi

Dilek GÜNAY CANPOLAT1, Nükhet KÜTÜK2 Canay Yılmaz ASAN2, Alper ALKAN2

Makale Kodu/Article Code : 400765 Makale Gönderilme Tarihi : 02.03.2018 Kabul Tarihi : 17.05.2018

ABSTRACT ÖZ Objective: Due to lack of past experiences and Amaç: Diş hekimi korkusu olan çocuklarda kooperasyon cooperation in anxious and fearful children, tooth kurulamaması ve daha önce geçirilen diş tedavileri nedeni extraction may be difficult to manage in . The ile diş çekimi zordur. Bu çalışmanın amacı, derin sedasyon aims of this retrospective study were to evaluate the ile diş çekimi yapılan çocuklarda uygulanan farklı various sedation techniques, complications and the sedasyon tekniklerini ve komplikasyonlarını characteristics of children whose tooth extraction were değerlendirmektir. performed with deep sedation. Gereç ve Yöntem: Erciyes Üniversitesi Lokal Etik Materials and Methods: After approval by the Local Komitesinin onayı alındıktan sonra, 2012-2014 yılları Ethics Committee, a retrospective analysis was performed arasında derin sedasyon ile diş çekimi yapılan, yaşları 1 ile using the records of 885 patients who were treated with 15 arasında 885 hastanın kaydı geriye dönük deep sedation for tooth extraction between the ages of 1- değerlendirildi. Çocuklara ait veriler, sedasyon teknikleri 15 years for the period between 2012 and 2014The authors ve komplikasyonlar belirlendi. described the characteristics of the children, the sedation Bulgular: Hastaların ortalama kilosu 20,09±7,3 kg ve techniques used; and the complications. ortalama yaşı 5,72±2,5 iken, ortalama işlem süresi Results: The mean weight of the patients was 20.09±7.3 16,14±5,4 dakikaydı. Anestezi amacıyla , kg and the mean age was 5.72±2.5 years. The mean ketamin, propofol-ketamin kombinasyonu, alfentanil, duration of the operations was 16.14±5.4 minutes. , sevofluran inhalasyonu, sevofluran Propofol, , propofol-ketamine combination, inhalasyonu+propofol kullanıldı. Post operatif alfentanil, midazolam, inhalation, sevoflurane komplikasyonlar açısından anestezik ajanlar arasında inhalation + propofol were used for the . There istatistiksel olarak anlamlı bir fark bulunamadı (p>0,05). were no statistically significant differences among the Sonuç: Sonuç olarak; işlem süresinin kısalığı, hızlı anesthetic agents for post-operative complications derlenme ve daha az bulantı-kusma gibi nedenlere bağlı (p>0.05). olarak pediatrik dental işlemlerde, derin sedasyon Conclusions: We concluded that propofol was a better amacıyla propofol daha etkili bir yöntemdir. Ketamin- option for deep sedation in pediatric due propofol kombinasyonu, yalnız propofole alternatif bir to short duration time, rapid recovery and less nausea- yöntem olarak kullanılabilir. vomiting. Ketamine-propofol combination may be used as Anahtar kelimeler: çocuklar, sedasyon, diş çekimi an alternative to propofol alone.

Keywords: children, sedation, tooth extraction

116 1 Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Erciyes University, Assistant Professor in , Kayseri, Turkey 2 Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Erciyes University, Kayseri, Turkey 2 Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Bezmialem University, Professor, Kayseri, Turkey Retrospective Evaluation of Sedation Techniques for Tooth Extraction in Pediatric Patients

INTRODUCTION MATERIAL AND METHODS Dental procedures are generally performed The study protocol was approved by the under . However, many fearful Local Ethics Committee (2014/389). The patients, especially children, are generally research was designed as a descriptive study; difficult to manage in dentistry due to lack of and a retrospective analysis was performed cooperation.1 Eradicating anxiety and avoiding using the hospital records of the patients. The possible psychological trauma in pediatric study population was composed of pediatric patients may prevent the development of dental patients who were admitted to our department phobia in children and behavior management between 2012-2014 and who were treated with problems when they become adults. Many deep sedation for tooth extraction. Inclusion behavioral management techniques are often criteria for the study were the absence of severe suggested to solve the anxiety of children in organ dysfunction, patients who had no dental offices. “Tell-show-do” is the most contraindication to be treated under general popular technique for this purpose.2,3 anesthesia, and patients aged 1 to 15 years. The Nevertheless, these techniques may be exclusion criteria were severe organ insufficient; and conscious sedation or deep dysfunction, returning to general anesthesia sedation, or general anesthesia may be because of the procedure being not performed considered as a sedation method to facilitate with deep sedation, and patients who had an dental treatment. Numerous anesthetic allergy to the drugs used. techniques such as midazolam-sufentanyl and All patients received an anesthetic ketamine-midazolam combinations, oral assessment in the preoperative period and, when midazolam, chloral hydrate and ketamine and necessary, medical consultations related to their propofol are used in pediatric dental specific medical conditions with the relevant treatment.4,5 department were obtained. Administrative and The Oral and Maxillofacial Surgery Clinic clinical details, and the American Society of of our university provides comprehensive Anesthesiologists Physical Status Classification dental treatment for children under 18 years of (ASA) status and medical conditions of the age, and adults with special needs who require patients, age, gender, anesthetic agents used for certain surgical techniques. Most of these deep sedation, routes of administration, patients are referred to this clinic from indication for tooth extraction, the number of surrounding districts for dental treatments that extracted teeth, duration of the operation, and must be performed with sedation or under complications were recorded. Informed general anesthesia. Although tooth extraction is consents were received from all parents before commonly performed with local anesthesia in the procedure regarding the anesthesia outpatient clinics in most children; for a techniques and the dental treatment to be minority of children, deep sedation may be performed. required to perform this procedure. All patients were pre-medicated using The aims of this retrospective study were midazolam 0.05 mg/kg intravenously (IV), or to evaluate the characteristics of children whose 0.5 mg/kg orally in patients with difficult tooth extractions were performed with deep vascular access just before the procedure. The sedation, to discuss various sedation techniques patients were taken into the operating room, and used, and also to evaluate the complications non-invasive standard was applied observed after the application of these including assessments of heart rate (HR), procedures in children in our clinic. peripheral oxygen saturation (SpO2), and electrocardiography (ECG). Supplemental

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Retrospective Evaluation of Sedation Techniques for Tooth Extraction in Pediatric Patients oxygen (3-4 L/min) was administered via a Table 1. The systemic diseases of the patients nasal mask. Patients were advised to fast for 4- The systemic diseases Patients (n) 6 hours before the procedure according to their Alegille 1 age, and oral intake with liquids was allowed 2 ALL 1 hours after the procedure. The patients were Anemia 5 discharged on the day of the operation if they Apert Syndrome 1 did not need to be observed closely for their Asthma 17 specific medical conditions. The residents of Renal Disease 1 oral and maxillofacial surgery department CP 3 performed all extractions. Down syndrome 6 Patients were divided into seven groups Epilepsy 21 according to the type of the anesthetic agent FMF 1 used. The following drugs were administered to Hydrocephaly 1 the patients: 1 mg kg-1 of propofol (IV) in Group Hyperactivity 3 P, 1 mg kg-1 of ketamine (IV) in Group K, 1 mg AuditiveDisfunction 2 kg-1 of ketamine and 1 mg kg-1 of propofol (IV) Cardiac Disfunction 4 in Group KP, 0.1 mg/kg midazolam (IV) in Cortical Atrophy 1 Group M, 10 mcg/ kg-1 alfentanil (IV) in Group A, 1-2% sevoflurane: oxygen at a concentration Mental retardation 6 of 50:50 in Group S, and 1-2% sevoflurane: Autism 5 oxygen at a concentration of 50:50+1 mg kg-1 of Talassamia 1 propofol (IV) in Group SP. TyroidDisfunction 2 West Syndrome 1 STATISTICAL ANALYSIS Total 83

Data were evaluated in the IBM SPSS 21.0 Values are expressed as n software program (IBM SPSS 21.0, Statistical The anesthetic agents used for sedation and the Package for Social Sciences, Chicago, Illinois, indications for tooth extraction are given in the USA). Categorical variables were compared Table 2. with the exact method of the Chi-Square test. A p<0.05 value was considered significant. Table 2. The anesthetic agents used for sedation The anesthetic agents %, n

RESULTS Propofol 82.3, 728

Total 885 patient records were included in the Ketamine 1.1, 10 study. The patients consisted of 372 (42%) girls Midazolam 0.3, 3 and 513 (58%) boys. The mean age of the patients Alfentanil 4.3, 38 was 5.72±2.5 years, with a range between the ages Ketamine+propofol 9.8, 87 of 1 and 15 years. The mean weight of the patients was 20.09±7.3 kg. Of the 885 cases, 802 (90.6%) Sevoflurane 2.1, 19 and 83 (9.4%) belonged to ASA I and II, The indications for tooth extraction %, n respectively. 2777 teeth were extracted and the Dental decay 95.7, 847 mean number of the extracted teeth was 3.1±2.5 Dental abscess 4.3, 38

(p=0.466). The mean duration of the procedure Dental trauma 1.7, 15 was 16.14±5.4 minutes. Detailed systemic Supernumerary teeth 1.5, 13 disorders or medical conditions of the patients are Values are expressed as %, n given in Table 1.

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There were no statistically significant aggravating preoperative anxiety.8 It should be differences according to gender, indication for kept in mind that intravenous deep sedation extraction, tooth number, trauma or requires monitoring, provisions for emergency supernumerary teeth between the groups conditions and close observation during and (p>0.05). Nausea- vomiting was seen in a total after the procedure to avoid the catastrophic of 54 patients (6.1%) and sore throat was results of anesthetic interventions. In our detected in 16 patients (1.8%). Arrhythmia, hospital, these procedures are performed in the bronchospasm or hypoxia were not seen in any operating room and maximal safety measures of the patients. There were no statistically are taken. significant differences among the anesthetic Ketamine and propofol have been agents in terms of nausea vomiting and sore successfully applied to children for various throat (p=0.09, p=0.857, Table 3). operations.9 Propofol has a very rapid induction Table 3. Number and percentage of patients who have 10 postoperative complications and recovery rate. Lebovic et al. reported that Type of anesthetic agent Nausea and vomiting Sore throat the recovery time of pediatric patients with %, n %, n cardiac catheterization is shorter with propofol Propopol 5.1 (n=37) 2.1 (n=15) compared to ketamine; and suggested it for Ketamine+propopol 11.5 (n=10) 0 (n=0) daily operations as a more practical alternative. Alfentanil 10.5 (n=4) 2,6 (n=1) Therefore, propofol may be preferred for Ketamine 20 (n=2) - relatively short procedures.10 Dental treatments Inhalation 6.3 (n=1) - in which low doses of propofol are used have P values p=0.09 p=0.857 been shown to be effective in anxious children.1

Values are expressed as %, n. P-values <0.05 were considered Respiratory or cardiovascular depression and significant. hypoxia may occur when propofol is not well DISCUSSION titrated. When it is used alone, the rate of airway events may increase.8 In the present study, Dental anxiety may complicate dental propofol was the most preferred anesthetic treatment, especially in children. Managing agent for intravenous sedation in tooth anxious pediatric patients is one of the most extraction. There were no airway events or commonly encountered challenges in dentistry. hypoxemia (SpO2 <90%), which may have Most dental treatments can be performed with resulted from close observation of the patients non-pharmacological behavioral therapies in because of the oral procedure, or emergency pediatric patients. 3 When these methods fail, interventions with the jaw thrust maneuver conscious sedation through the administration when necessary, along with continued oxygen of inhalation can be an alternative supplementation. method. Nitrous oxide inhalation provides successful results in pediatric patients with Ketamine is the most popular anesthetic moderate anxiety levels; however, the success agent for brief and painful procedures. 9 rate decreases with the severity of anxiety, Ketamine usually maintains airway and leading to repeated procedures.6 Considering its respiratory function, and does not cause airway low efficiency and the potential side effects of loss, oxygen desaturation or significant clinical nitrous oxide,7 sedation with intravenous agents emergency reactions. Although it has become a may be a suitable option for dental procedures favorite in dental procedures, several adverse such as tooth extraction in children. It has been effects such as laryngospasm, transient reported that planned intravenous sedation respiratory depression, vomiting and prevents dental anxiety and provides a psychomimetic effects such as recovery comfortable and safe operation without agitation or hallucinatory reactions have been

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Retrospective Evaluation of Sedation Techniques for Tooth Extraction in Pediatric Patients documented.12,13 In this study, the incidence of anesthesia. They recommended this technique nausea vomiting was higher in the K group than for advanced adequately in the other groups. It was remarkable that the when used. In another study, Wood17 used it incidence of nausea-vomiting was higher in the successfully in the dental treatment of 500 KP group than the P group. Although these children requiring dental sedation. In our results were not statistically significant, they retrospective study, we determined that we have clinical importance. When propofol was employed midazolam in only three patients. The used in sub-anesthetic doses, less nausea- adequate sedation levels in patients who were vomiting was seen compared to ketamine alone. pre-medicated with midazolam preoperatively The antiemetic feature of propofol and the and who did not require an additional agent for emetic effect of ketamine may have caused this the procedure caused this result. Thus, the tooth result. Similarly, in a controlled study, upon extraction procedure could be easily performed procedural sedation, less vomiting was detected with midazolam without airway complications when a propofol-ketamine combination was or nausea and vomiting. used compared to when ketamine was used Alfentanil, an opioid analgesic agent, has alone.14 been used for tooth extraction or complete oral Guit et al.15 determined that propofol restorations under general anesthesia in reduced the side effects of ketamine at sub- pediatric patients.18,19 It may provide sedation anesthetic doses, and a ketamine-propofol and analgesia and may be related to a high rate combination supplied hemodynamic stability. of postoperative vomiting, as with all opioids. Also, the incidence of airway complications In our study, alfentanil was associated with a was reduced when propofol was combined with 10.5% incidence of nausea-vomiting, which ketamine.9 However, Shah et al.14 reported was two-fold higher than with propofol. similar efficiency and airway complications Inhalation agents are also used as a with ketamine alone or with a ketamine- sedation technique for dental treatment. propofol combination. In the present study, Whereas nitrous oxide is widely used for dental although the hemodynamic data were not sedation, it generally requires additional agents evaluated in detail, no incidences of arrhythmia to maintain an adequate level of sedation. were observed in any patients as a complication. Sevoflurane is a more potent anesthetic agent We did not encounter psychomimetic effects or than nitrous oxide; and has been used for hallucinations in any patient. This may be due conscious sedation in several dental to the preoperative midazolam administration procedures.7 Kim et al.20 suggested that before the patients were taken to the operating sevoflurane might be an alternative sedating room. agent in the pediatric dental outpatient setting. Midazolam has a rapid onset of action and In the present study, sevoflurane was employed high metabolic clearance, and can produce in patients in whom an intravenous approach , and an anxiolytic effect could not be used due to procedural difficulty. when administered via the oral, intramuscular Only three patients required additional propofol or intravenous route. Therefore, it has been used intravenously. Nausea and vomiting occurred in for premedication, anesthesia induction, only one of the patients whose tooth extraction maintenance or sedation for invasive was performed under sevoflurane anesthesia. procedures.16 Roelofse et al. 4 reported that the Sore throat is a complication that is usage of a combination of midazolam and commonly caused by endotracheal intubation, ketamine or midazolam alone was a useful dry airway gases or airway suction.21 In this approach for dental treatments under local study, although none of the patients were

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Canpolat D., et al. intubated and no supraglottic airway devices 5. Lourenço-Matharu L, Ashley PF, Furness S. were used, sore throat was observed at a low Sedation of children undergoing dental incidence. We believe that sore throat was most treatment. Cochrane Database Syst Rev. 2012; likely to have been caused by airway suction, 14:CD003877. which was used to provide better visualization 6. Major E, Winder M, Brook AH, Berman DS. and to remove blood and secretions. An evaluation of nitrous oxide in the dental In conclusion, propofol was the most treatment of anxious children. A physiological preferred anesthetic agent for deep sedation for and clinical study. Br Dent J. 1981;151:186- pediatric dental extractions due to its rapid 191. onset, recovery and low incidence of nausea and 7. Becker DE, Rosenberg M. Nitrous oxide and vomiting. The ketamine-propofol combination the inhalation anesthetics. Anesth Prog. may be a good alternative as it provides better 2008;55:124-130 analgesia. However, the ideal anesthetic agent should be chosen according to the medical 8. Seto M, Sakamoto Y, Takahashi H, Kita R, condition of the patient. Kikuta T. Does planned intravenous sedation affect preoperative anxiety in patients? Int J Acknowledgements: We thank Dr. Ferhan Oral Maxillofac Surg. 2013;42:497-501. Elmalı for his excellent assistance on the statistical analyses and Dr Mustafa Denizhan 9. Alletag MJ, Auerbach MA, Baum CR. Yıldırım for his contributions on this study. Ketamine, propofol, and ketofol use for There is no funding for this study. pediatric sedation. Pediatr Emerg Care. 2012;28:1391-1395 Conflict of Interest: Authors have no conflict of interest. 10. Lebovic S, Reich DL, Steinberg LG, Vela FP, Silvay G. Comparison of propofol versus REFERENCES ketamine for anesthesia in pediatric patients 1. Giovannitti JA Jr. Dental anesthesia and undergoing cardiac catheterization. Anesth pediatric dentistry. Anesth Prog. 1995;42:95- Analg. 1992;74:490-494. 99. 11. Hosey MT, Makin A, Jones RM, Gilchrist F, 2. Klingberg G, Vannas Löfqvist L, Bjarnason Carruthers M. Propofol intravenous conscious S, Norén JG. Dental behavior management sedation for anxious children in a specialist problems in Swedish children. Community paediatric dentistry unit. Int J Paediatr Dent. Dent Oral Epidemiol. 1994;22:201-205. 2004;14:2-8. 3. Farhat-McHayleh N, Harfouche A, Souaid 12. Bredmose PP, Grier G, Davies GE, Lockey P. Techniques for managing behaviour in DJ. Pre-hospital use of ketamine in paediatric pediatric dentistry: comparative study of live trauma. Acta Anaesthesiol Scand. 2009;53:543- modelling and tell-show-do based on children's 545. heart rates during treatment. J Can Dent Assoc. 13. Green SM, Roback MG, Kennedy RM, 2009;75:283. Krauss B. Clinical practice guideline for 4. Roelofse JA, Joubert JJ, Roelofse PG. A emergency department ketamine dissociative double-blind randomized comparison of sedation: 2011 update. Ann Emerg Med. midazolam alone and midazolam combined 2011;57:449-461. with ketamine for sedation of pediatric dental 14. Shah A, Mosdossy G, McLeod S, Lehnhardt patients. J Oral Maxillofac Surg. 1996;54:838- K, Peddle M, Rieder M. A blinded, randomized 844 controlled trial to evaluate ketamine/propofol

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