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In general, patients, children are usually nervous about three things. The first complaint from patients is often freezing. The delivery of local anaesthetic is usually uncomfortable because of the initial "pinch" of the needle. Then, the continued pressure of the injection is just as unpleasant. Second, all the things that we put in the mouth tends to be a lot, often causing the feelings of claustrophobia. It is quite common to feel very "gaggy" with the placement of the rubber dam. Third, all those noises and vibrations create anxiety especially in children. From the high-pitched whistle of the high-speed drill, to the deep rumblings of the slow-speed drill, and to the loudness of the suction, all lead to increased tension. All of these things create anxiety in children, and often adult patients as well. Unfortunately, we cannot avoid any of these things.
If we understand these concerns, we can approach treatment in different ways. First, we could just do it. Unfortunately, this usually doesn't go over well especially if multiple appointments are needed. The first treatment visit is always easy because the child does not know what to expect. As a result, they often don't say anything or will not react. However, the second treatment visit is always the test because they will remember things and will eventually be brave enough to say something and/or act out.
If we don't think a child can tolerate multiple appointments without difficulty, we can use "laughing gas" (nitrous oxide). Laughing gas is a very mild sedative. Often, a patient's fingers and toes will feel tingly, they feel light-headed and somewhat relaxed. It takes about 5 minutes to start working and is usually gone within 5 minutes after if pure oxygen is administered. The biggest problem with using laughing gas is still cooperation. The mask sits on the nose and if the patient cannot breathe through their nose, the gas does not work. Similarly, if treatment is going well but the child gets upset or stubborn, nose breathing often stops and the effects are lost. Then, treatment is like without any gas.
If parents don't think that the laughing gas will be enough or if they think there might be a cooperation problem, the next step is an oral sedative. Although there are many types, the drug of choice in children is Versed (Midazolam). Versed is a water-soluble benzodiazepine which is in the same family of drugs as Avtivan (Lorazepam) and Valium (Diazepam). Because of its bitterness, Versed is mixed with some grape juice or chocolate syrup to increase acceptance. Possibly, the "laughing gas" may be administered with the sedative which potentiates the effects. This does require preparations and precautions.
For those kids who are "not sedatable" and often get worse when medication(s) is administered, the last option, and I like to leave it as a last option, is a general anaesthetic (GA). A child is taken to the operating room, is put to sleep and all of the dental work is done at once. This method sounds very easy and convenient, but there are many drawbacks. First, there is always health risks with a GA, which include cardiac arrest, respiratory arrest and even death. Second, a GA is not a pleasant experience and children often feel nauseated and will vomit for the rest of the day afterwards. Third, there is often a 6 month waiting list due to the lack of time available. During the waiting period, the severity of your child's needs may increase quite substantially. Some patients have no choice and automatically require a GA to complete their work (the very young, special needs, extensive treatement, etc.). An initial evaluation between the child and the doctor will often determine the appropriate course of action.
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