A technique in which the use of a drug or drugs produces a state of depression of the central nervous system enabling treatment to be carried out, but during which consciousness and verbal contact with the patient is maintained throughout the period of sedation. The drugs and techniques used to provide conscious sedation for dental treatment should carry a margin of safety wide enough to render loss of consciousness unlikely.

The most commonly used techniques in children are:

• Inhalation sedation with nitrous oxide/oxygen (see right)
• Oral sedation using midazolam

Other techniques include:

• Intravenous using midazolam or propofol (in the adolescents)
• Nasal/transmucosal using midazolam

Inhalation sedation with Nitrous Oxide/Oxygen:

• The nitrous oxide is titrated to get effective conscious sedation
• This technique will require a cooperative child who will accept a nasal hood
• Works well when behaviour management techniques are involved
• The onset of sedation can be initiated over 5 minutes
• There is minimal impairment of protective reflexes
• Nitrous Oxide has some mild analgesic property
• Nitrous Oxide is administered continuously through a nasal hood (mask)
• Useful for anxious but compliant children
• Nitrous Oxide is a pollutant and therefore all efforts is made to ensure its used safely to prevent pollution and reduce the risks of chronic exposure to staff

Oral Sedation:

The agent that has been used is midazolam at 0.3 – 0.5mg/kg. In general, this is not commonly practiced as it can be unpredictable and getting access to oral midazolam can be challenging. Often, it is mixed with juice to mask the taste. It can be used for young children for simple procedures e.g. single tooth extractions. It is generally felt that to practice oral sedation safely, the operator/team should be skilled in cannulation to be able to gain access in case of over-sedation.

Other features:

• Can be unpredictable
• Unable to alter sedation effects
• Can take up to 40 minutes to take effect
• Duration of effect is around 30 minutes
• Recovery is around 30 minutes
• Can produce good sedation and amnesic effect

Other recognized forms of sedation

Intravenous sedation:

Intravenous sedation (IV) for the adolescent patients (12 years onwards) can be effective. The most commonly used single drug sedation is Midazolam but propofol can also be effectively used. Propofol is a general anaesthetic agent and therefore this will require an anaesthetist to provide the sedation.

Nasal/Trasmucosal Sedation:

• Midozolam is used like a nasal spray using Mucosal Atomization Device (MAD)
• 0.25 mg/kg of midazolam is administered using a MAD
• Is not commonly used in paediatric dentistry as it can have a profound effect
• Can be used in an appropriate environment with anaesthetist support

General anaesthesia

When all options for management of the child under LA or sedation has failed or not possible, treatment under GA may need to be considered.

Children should be assessed prior to the GA. All options of pain and anxiety management should be considered. Assessment should ideally include radiographs and orthodontic opinion where it is appropriate. The treatment plan for the GA should also take into account prevention. Written consent is completed by a parent/carer who has parental responsibility and is re-confirmed on the day of the GA. Information leaflet with fasting instructions and pre/post operative care is provided during the assessment.

The most common GA lists in the UK are for extractions only. It is vital that all carious teeth are included in the treatment plan. In some units, it is possible to do restorations and extractions or comprehensive care under GA. Restorations on these lists including fissure sealants are ideally completed under rubber dam.