Clinical Impact of Local Anesthesia on Sedation Stability and Propofol Dosage in Pediatric Dental Sedation

Abstract

Background: Local anesthesia (LA) is often preferred for stabilization of vital signs, depth of anesthesia and pain control in dental restorations but the efficacy of LA administration during deep sedation is controversial. Aim: To retrospectively investigate the effects of LA on heart rate, blood pressure, oxygen saturation, depth of anesthesia and total dose of anesthetic drugs given in pediatric patients sedated for dental procedures. Materials & Methods: Records of 50 healthy children were divided into two groups: Patients who received infiltration LA at the beginning of sedation (Early LA) or who received LA at the end of sedation after completion of restorations (Late LA). Demographic data, hemodynamic data, Bispectral Index (BIS) scores, Ramsey Sedation Scale scores, total propofol dose administered were compared. Since the difference between two quantitative dependent variables did not meet the assumptions of normal distribution, Wilcoxon Signed Rank test was used. Generalized Estimation Models were used to look at the effect of quantitative variables with repeated measures (BIS and Ramsey) on groups. Results: There was no statistically significant difference between the groups in terms vital signs, depth of anesthesia (BIS (p=0.190) and Ramsey score (p=0.887)), and total propofol dose adjusted for BMI (p=0.59). Conclusion: The presence of LA during deep dental sedation has no significant impact on vital signs, depth of anesthesia and total amount of propofol used compared to the absence of LA. LA does not contribute to stabilization of dental sedation, but close monitoring of deep sedation prevents drug overdose.

Keywords

• dental sedation
• pediatric anesthesia
• propofol
• local anesthesia
• monitoring

References

1. Klingberg G, Broberg AG. Dental fear/anxiety and dental behaviour management problems in children and adolescents: a review of prevalence and concomitant psychological factors. Int J Paediatr Dent. 2007;17(6):391–406. doi:10.1111/j.1365-263X.2007.00872.x.
2. Ahmed SS, Hicks SR, Slaven JE, Nitu ME. Deep sedation for pediatric dental procedures: Is this a safe and effective option? J Clin Pediatr Dent. 2016;40(2):156–160. doi:10.17796/1053-4628-40.2.156.
3. Coté CJ, Wilson S. Guidelines for monitoring and management of pediatric patients before, during, and after sedation for diagnostic and therapeutic procedures. Pediatrics. 2019;143(6). doi:10.1542/peds.2019-1000.
4. Zouaidi K, Olson G, Lee HH, Kalenderian E, Walji MF. An observational retrospective study of adverse events and behavioral outcomes during pediatric dental sedation. Pediatr Dent. 2022;44(3):174–180.
5. Parekh S, Gardener C, Ashley PF, Walsh T. Intraoperative local anaesthesia for reduction of postoperative pain following general anaesthesia for dental treatment in children and adolescents. Cochrane Database Syst Rev. 2014;2014(12):Cd009742. doi:10.1002/14651858.CD009742.pub2.
6. Townsend JA, Hagan JL, Smiley M. Use of local anesthesia during dental rehabilitation with general anesthesia: a survey of dentist anesthesiologists. Anesth Prog. 2014;61(1):11–17. doi:10.2344/0003-3006-61.1.11.
7. Anand P, Wilson R, Sheehy EC. Intraligamental analgesia for post-operative pain control in children having dental extractions under general anaesthesia. Eur J Paediatr Dent. 2005;6(1):10–15.
8. El Batawi HY. Lidocaine use for pain management during pediatric dental rehabilitation under general anaesthesia. Eur Arch Paediatr Dent. 2013;14(6):381–387. doi:10.1007/s40368-013-0027-6.

9. Watts AK, Thikkurissy S, Smiley M, McTigue DJ, Smith T. Local anesthesia affects physiologic parameters and reduces anesthesiologist intervention in children undergoing general anesthesia for dental rehabilitation. Pediatr Dent. 2009;31(5):414–419.
10. Wilson IH, Richmond MN, Strike PW. Regional analgesia with bupivacaine in dental anaesthesia. Br J Anaesth. 1986;58(4):401–405. doi:10.1093/bja/58.4.401.
11. Coulthard P, Rolfe S, Mackie IC, Gazal G, Morton M, Jackson-Leech D. Intraoperative local anaesthesia for pediatric postoperative oral surgery pain–a randomized controlled trial. Int J Oral Maxillofac Surg. 2006;35(12):1114–1119. doi:10.1016/j.ijom.2006.07.007.
12. Moness Ali AM, Hammuda AA. Local anesthesia effects on postoperative pain after pediatric oral rehabilitation under general anesthesia. Pediatr Dent. 2019;41(3):181–185.
13. Luo W, Zheng K, Kuang H, Li Z, Wang J, Mei J. The potential of articaine as a new generation of local anesthesia in dental clinics: A review. Medicine (Baltimore). 2022;101(48):e32089. doi:10.1097/md.0000000000032089.
14. Chen SC, Chen CY, Shen SJ, Tsai YF, Ko YC, Chuang LC, et al. Application of Bispectral Index System (BIS) Monitor to ambulatory pediatric dental patients under intravenous deep sedation. Diagnostics (Basel). 2023;13(10):1789. doi:10.3390/diagnostics13101789.
15. Powers KS, Nazarian EB, Tapyrik SA, Kohli SM, Yin H, van der Jagt EW, et al. Bispectral index as a guide for titration of propofol during procedural sedation among children. Pediatrics. 2005;115(6):1666–1674. doi:10.1542/peds.2004-1979.
16. Ramsay MA, Savege TM, Simpson BR, Goodwin R. Controlled sedation with alphaxalone-alphadolone. Br Med J. 1974;2(5920):656–659. doi:10.1136/bmj.2.5920.656.
17. Townsend JA, Ganzberg S, Thikkurissy S. The effect of local anesthetic on quality of recovery characteristics following dental rehabilitation under general anesthesia in children. Anesth Prog. 2009;56(4):115–122. doi:10.2344/0003-3006-56.4.115.
18. Han D, Pan S. Comparison of analgesic efficacy of local anesthetic infiltration and ultrasound-guided abdominal wall nerve block in children undergoing ambulatory inguinal hernia repair. J Perianesth Nurs. 2022;37(5):699–705. doi:10.1016/j.jopan.2021.12.006.
19. Leong KJ, Roberts GJ, Ashley PF. Perioperative local anesthetic in young pediatric patients undergoing extractions under outpatient ‘short-case’ general anaesthesia: A double-blind randomized controlled trial. Br Dent J. 2007;203(6):E11–335. doi:10.1038/bdj.2007.724.
20. Lin YJ, Wang YC, Huang HH, Huang CH, Liao MX, Lin PL. Target-controlled propofol infusion with or without bispectral index monitoring of sedation during advanced gastrointestinal endoscopy. J Gastroenterol Hepatol. 2020;35(7):1189–1195. doi:10.1111/jgh.14943.
21. Morse JD, Cortinez LI, Anderson BJ. Considerations for intravenous anesthesia dose in obese children: Understanding PKPD. J Clin Med. 2023;12(4):1642. doi:10.3390/jcm12041642.
22. Rogerson CM, Abulebda K, Hobson MJ. Association of BMI with propofol dosing and adverse events in children with cancer undergoing procedural sedation. Hosp Pediatr. 2017;7(9):542–546. doi:10.1542/hpeds.2016-0191.