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PHARMACOLOGICAL METHODS OF

BEHAVIOUR MANAGEMENT

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• AIM
• OBJECTIVE
• TERMINOLOGIES
• PRE ANAETHETIC EVALUATION
• ANATOMIC & PHYSIOLOGIC DIFFERENCES BETWEEN
CHILD AND ADULT
• METHODS
• PREMEDICATION
• GUIDELINE FOR PREMEDICATION
• SUMMARY
• REFERENCES

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 AIM: The performance of painless
procedure for the child is one of
the key factor in establishing a
good rapport.
OBJECTIVE:
1. To Provide the most comfortable, efficient,
and high quality dental service for patient.
2. To control inappropriate behaviour on the part
of the patient that intenders with such
provision care.
3. To thus produce in the patient a positive
psychologic attitude toward future care.
4. To return the patient to the pretreatment
condition. By the time of discharge.
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 TERMINOLOGIE
S :
• Conscious sedation – a minimally depressed
level of consciousness that retains the
patient’s ability to maintain an airway
independently and respond appropriate to
physical stimulation & verbal command.
• Deep sedation:- a controlled state of
depressed consciousness accompanied by a
partial loss of protective reflexes, including
inability to respond purposefully to a verbal
command.
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• General anesthesia- a controlled state of
unconsciousness accompanied by partial
or complete loss of protective reflex
including independently and respond
purpose fully to physical stimulation or
command.
• Ambulatory outpatient- or day care
anesthesia- refers to the delivery of
anesthesia care in which patient are
discharged on the day of treatment.
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 Pre anAesthetic evaluation
1. INFORMED CONSENT
2. PREOPERATIVE INSTRUCTION

• Instructions to parents:-

• information in written form should be

reviewed with the person caring for the child
& given to them along with the notice of the
scheduled appointment.

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(1) No solid food should be taken after midnight
before the sedation appointment.
(2) Includes milk since it becomes a solid once
induced to the acidic environment of the
stomach.
(3) Children under 3 years of age may have clear
liquids upto 4 hours before the procedure.
(4) For those 3 to 6 years of age upto 6 hours
before it, and for children 7 and older &
hours before coming to office

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REASON:-The reason for these recommendation two
fold.
 First since most conscious sedation agents are
administered by the oral route drug uptake is
maximized when the stomach is emptily.

 Secondly emesis during or immediately after a

sedative procedure is a potential complication in
that aspiration of stomach content can cause
laryngospasm or severe airway obstruction and may
even present difficulties later in the form of
aspiration pneumonia.

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3. PRE –OPERATIVE ASSESMENT
It should be done within 2 weeks prior to the
procedure to be reviewed at the time of
treatment.
Health History – in this includes.
• Histories of allergies/ allergic reaction current
medications including dose time,
• Route and site of administration.
• Disease, disorder, abnormalities.
• Family history.
Review of system–mainly the respirators &
cardiovascular systems are very important.
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 Anatomic & physiologic
difference b/w child & adult.
 Basal metabolic activity is measured in calories
per hour, per square meter of surface area that the
smaller the patient the greater the relative surface
area of the patient this becomes a far better entering
of fluid, nutritional and drug response than either
age or weight.
 Airway management requires different
consideration in the pediatric patient because of
anatomic variation. The narrow nasal passage &
glottis combined with hypertophic tonsils and
adenoids enlarged tongue and greater secretions
produce a much greater risk of airway obstruction.
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 Children demonstrate a reduced tolerance to
respiratory obstruction sudden apnea is a greater
concern with the pediatric age group.
 Cardiovascular parameters are different for children
the heart rate is faster and the blood pressure is
lower than in adult patient.
 The effect & duration of drug is much more variable
for children for agents that are more lipophilic there
may by prolonged retention, especially in children
who may be obese for some type of patient drug
metabolism may be increased because of better
peripheral perfusion in children the onset of effect
may be more rapid.
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 • METHODS:-
1. Sedation
2. Conscious Sedation
3. General Anaesthesia
Sedation
Routes of administration Indications and benefits Limitations and risks

1. Inhalation: (Nitrous  Can be used for mild to • Agent has weak potency
oxide) moderate levels of anxiety. •It can be used to decrease the
 Analgesia for brief, comfortable anxiety levels, but not in
procedures children with severe behaviour
 Rapid onset and early elimination problems.
Also can not be used in
and recovery. claustrophobic patients,
 The duration of action can be easily respiratory taract infections.
Controlled

II. Oral (Several drugs are Can be used for preoperative sedation. • Delayed onset of action
used) Used for all levels of anxiety. coupled with unpredictable
Better acceptability and ease of administration. absorption.
The incidence of ARD is less. •Depends on patient
compliance.
•Difficulty in determining drug
dosage.
•Trained personnel proficient in
management of unconscious
patient required.

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 Routes of administration Indications and benefits Limitations and risks
A. Hydroxyzine Mild sedative along with antimetic and•Better used in combination with
(Vistaril) anticholinergic action. other agents.
25 mg/5cc) Potentiates narcotic and CNS
depressants.

B. Promethazine  Same as above •For mild levels of anxiety only

(Phenergan) •Better used in combination
(12.5 mg/5cc,
2.5 mg/5cc)

C. Chloral hydrate  For all levels of anxiety •Not recommended in children

(Noctec)  Long working time below 6 years of age.
(500 mg/ 5cc) Believed to have & wide range of safety.• Agitation common in the latent
period and as effects dissipate.
•No analgesia
•Maximum dose not to exceed
1500 mg.

D Meperidine  Best used in combination for • Poor oral absorption

( Demerol) 1. Brief procedures with
(50 mg/ 5cc) promethazine or hydroxyzine
2. Longer procedures with chloral
hydrate. www.FourthMolar.com
•Contraindicated in children with
COPD, Hypothyroid or liver
dysfunction.
 Routes of administration
E. Diazepam (Valium)
( 5 mg/5cc elixir,
2,5,10, 15- mg
Tablets )
F. Triazolam (Halcion) 0.125, 0.25 In addition has anticonvulsant activity. • Safety guidelines not fully
mg tablets)
G. Chorpromazine
(THorazine)
(10 mg/mlsyrup, 10, 25, 50, 100, Useful in severe behaviourla problems.
200 mg tablets )
III. Intramuscular
Indications and benefits Limitations and risks
 Safe agent for mild to moderate anxiety• Multiple doses required to
particularly in children with cerebralachieve sedation.
palsy, mental retardation. • Not effective in severe anxiety
Children less than 6 years of age. when used alone.
Oral absorption equally good as
parentral
 Good oral absorption established.
 Used in combination (Lytic cocktail)• Unpredicatable and less studied.
with meperidine or promethazine.
 Rapid onset of action • Injection required and will not be
 More reliable with little patientliked by children.
compliance. •May cause injury during
administration.
•Limited control over reversibility.
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 Routes of administration Indications and benefits Limitations and risks
1. Ketamine  Dissociative anesthesia where a • Safety of oral use not yet
(ketalar) cataleptic state can be injuced. established.
(10 and 50 mg/ml) Potent analgesic.
Potential for oral use.

2. Midazolam  Possesses hypnotic, anticonvulsant and• Little data for effective dose
(Versed) muscle relaxant properties as well asin pediatric context.
being antegrade amnesic and anxiolytic. •Used mainly for short
(1 and 5 mg/ml)
 Greater potency as compared toprocedures.
diazepam.
Rapid onset of action.

IV. Intravenous  Most rapid onset of action. • Requires extensive

(Commonly used is Midazolam)  Permits titration and is easily reversible.armamentarium, training
 Maintains a line for emergency drugs. (specially in pediatric cases
due to anatomic and
Best for invasive procedures of shortbehavioural considerations)
duration.
• Precautions to be taken in
significant hepatic or thyroid
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 CONSCIOUS SEDATION

Agents commonly used for conscious sedation.

• Nitrous oxide
• Tranquilizers (eg. Bonzodiazepins)
• Chloral hydrate (alcohol)
• Barbiturate
• Narcotics
• Antihistamins

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S.No. Agents Properties Dosage Adverse drug reaction
Nitrous oxide  It is a sweet smelling,  Depression of bone marrow after
colourless inertgas. prolong use.
 Heavier than air.  On long term exposure to high
 Non- inflammable. ambient level of gas it may arise
 Always coupled with more serious complication like spontaneous
than 40% O2 abortion, increase in hepatic ds.
 Rapidly absorbed from luxy
laveole with rapid excretion.

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2. Benzodiazep  This is a lipid solubleOral/ rectal Ataxia & prolonged CNS
in Diazepam and water insoluble durg. 0.2 – 0.5depression are important drug
 On oral administration itmg/ Kgreactions.
is rapidly absorbed andI.V. 0.25
reaches peak level twomg/ Kg
hours but the bio-
transformation is quite
slow with a half life of 20-
40 hours
On I.V. administration
patient seems not be
sedated though free from
anxiety
It’s anticonvulscent
action provide some
protection against adverse
reaction

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2. Midazola Adult dose 0.1 – . Respiratory Depression
• It is a water soluble hence0.I5 mg/ Kg Hypertension
m less possibility ofPediatric dose
thrombophelibitis. I.V. – 0.5- 0.1/
mg/kg
• Sedation occurs in 3-5 mins
after i.v. administrationOrally – 0.03–0.75
mg/kg rectally-
recovery takes place in 2-60.4- 1 mg/kg.
hours without any rebound
phenomenon. Rasally – 0.2 –
0.3mg/kg.
• The drug has rapid
absorption and rapid
elimination.

3. Chloral •Onset of action 15-3025-50 mg/ Kg  Respiratory depression

mins when given orally. • Depression of Myocardium
hydrate arrythmias.
• The drug is irritating to •Prolonged drowsiness or sleep.
gastric mucosa & can
cause nausea & vomiting.
• Produce a period of
excitement & inability
before sedation.
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4. Barbitura Short acting Respiratory Depression
tes C.N.S. Depression.

Narcotics •A syntheticopoid1-22 mg/ kg.  Respiratory Depression

(i) agonist. Not to exceed  Reduce the patient’s seizure
Meperidine • Can be administered100 mg. threshold.
orally subcutaneously.
• It is incompatible
drug in solution like
barbiturates

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III. Fentanyl • Very Potent 0.002 – 0.001 mg/ Kg  Respiratory Depression
•Rapid Onset After S.C. or  Airway Management
I.V. Administration

6. Antihistamin

I. Hydroxyzine • Rapid absorption withOral 0.6 mg/Kg Extreme drowsiness dry mouth,
onset of action in 15-301.M – 1.1 mg/ kg hyper sensitivity wheezing, dys-
mins with peak at 2 hours pnoea & chest tightness.
after local administration.
• It can be used I.M. but
never s.c.

II. Promethazine Can be used orally or I.M. Oral  Blurred vision

• Well absorbed after oral1Mg/Kg.  Mild Hypertension
ingestion.  Extrapyramidal effect.
• Should be covetously used
in a children with a history
of sleep, apnea.

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 3. GENERAL ANAESTHESIA
INDICATION:-
• Physically, mentally or medically challenged patient.
• Patients with dental needs for whom LA is inefficient
bcoz of acute infection, anatomic variations or allergy.
• Extremely uncopperative fearful anxious- or
concomincenicative child or adolescent with dental
needs considered sufficiently that dental care can’t be
avoided.
• Pts. Who have sustained extensive oro-facial or
dental trauma .

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CONTRAINDICATION
• Health patient with minimal
dental need.
• Medically contraindicated pts.

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PREMEDICATION:-
It is the administration of drug before an anesthesia
with a view to facilitating operation & anaesthesia.
Indication:-
• V. young children ( 3 years & before)
• V. Appreprensive children.
• Physically handicapped children (like cerebral
palsy) .
• Children who are mentally handicapped.

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 GUIDELINES OF
PREMEDICATIONS-
• Infants under 1 years
Atropine 0.02 mg/Kg – i.v. at anasthesia
i.m. 30 min before
• Healthy children 1-3 years of age
Atropine 0.02 mg/kg – i.v. at anaesthesia
i.m. 30 minutes
before
• Healthy children over 3 years of age
* Optimal psychological management.
* If indicated add 4mg/kg diazepan suspesion
* Atropine 0.02 mg/kg – i.v. at anaesthesia
i.m. 30 minutes before.
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 REFRENCES
• Shobha Tandon:- TEXT BOOK OF
PEDODONTICS
• Edition 2001 :- Page No. 155,156
• RALPH E. Mc DONALD DAVID R. AVERY:-
Dentistry for child and adloscent.
• SIXTH ADDITION
• GORAN KOCH :- PEDIATRIC DENTISTRY
• EDITION 2001: Page No. 168,170

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