Dental procedures are often necessary for pediatric patients with dental health problems. However, perioperative anxiety and fear is common in this age group. Despite planning intravenous sedatives for the procedures, pediatric patients are often unwilling to cooperate with venipuncture and may actively resist intravascular catheter placement. Unpleasant venipuncture experiences can lead to psychological trauma and increases difficulty to proceed with future treatment. Non-intravenous premedication could be of potential benefit in these situations. In this case report, we discussed the use of intranasal dexmedetomidine as sedation premedication before dental procedures.
A 3-year-old boy (body weight, 15 kg and body height, 96 cm) was diagnosed as having dental caries and pulpitis. He was apprehensive of the hospital setting and was easily distressed, making him unable to accept dental procedures under local anesthesia. After consultation with our anesthesiology department, dental management (including composite resin filling, root canal treatment, crown restoration for primary teeth, and application of pit and fissure sealant) was planned to be performed under intravenous sedation with fentanyl and target control infusion (TCI) with propofol.
On the day of the procedure, he was pre-medicated with intranasal dexmedetomidine 80 mcg. After 30 min, intravenous catheter was installed under mild sedation in the company of family members. Propofol infusion was administered via target controlled infusion pump (Kataria model), with initial effect site concentration set at 2 mcg/ml. The sedation level was targeted to reach observer's assessment of alertness/sedation level four. High flow nasal cannula (Optiflow™) was then implemented with FiO2 1.0 and flow rate 30 L/min.1 The dental treatment was completed smoothly with only a few interruptions due to coughing of the patient. Neither airway obstruction nor desaturation was observed throughout the procedure.
Contemporary choices of premedication for dental anesthesia includes intranasal midazolam, intramuscular ketamine, and intranasal dexmedetomidine. Intranasal midazolam is effective as a hypnotic agent. However, adverse effects may include intranasal burning sensation and respiratory depression. Intramuscular injection is painful which limits clinical applications of intramuscular ketamine. Ketamine is also associated with excessive salivation, hallucinations, nausea, vomiting, tachycardia, and hypertension. Dexmedetomidine is a highly selective alpha 2-adrenergic agonist, which has already been utilized intravenously or intramuscularly for sedation of pediatric patients undergoing radiological imaging.2 Recently, intranasal dexmedetomidine has been adapted as a premedication for dental sedation, making use of its hypnotic and analgesic effects.3,4 The dose of 4 mcg/kg of intranasal dexmedetomidine is generally sufficient for anxiolysis and mild sedation. There is minimal respiratory suppression of dexmedetomidine, and family members are able to accompany the pediatric patients in the waiting room while the sedation takes effect. According to literature, time to reach peak plasma concentration of intranasal dexmedetomidine is on an average of 38 min for healthy adults. Dexmedetomidine also has the benefit of reducing emergence delirium, making it an attractive potential alternative premedication in the setting of dental care.5
Through providing sedation to smooth the preparation process before dental procedures (including the placement of intravenous catheters), dexmedetomidine as premedication helps in providing a better dental experience for patients, their families, and medical staffs.
References
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