1. Premedication Pain managment

2. Measurement of pain in children Observer-based techniques which are useful in pre-verbal children, blood pressure, crying, movement, agitation and verbal expression/body language. Self-reporting of pain is valid in children over 4–5 years of age. Older children and teenagers can use a normal visual analogue scale of 1–10. Mentaly handicaped children - difficult to assess - unusual changes in behaviour

3. Analgesia prior to procedures (pre-emptive analgesia) ensure adequate systemic and/or local analgesia prior to the commencement of a procedure Appropriate time for absorption and effect should be allowed. A stronger analgesic may be required for the procedure with regular simple analgesics for the postoperative period.

4. Routes of administration Per os - is the preferred route of administration in children. absorption for most analgesics is generally rapid – within 30min liquid vs. tablets in younger children, taste - can help greatly with compliance Per rectum - in a child who is fasting or not tolerating oral fluids. peak levels are usually much longer (paracetamol 90–120 min) - not used in the immunocompromised child due to the risk of infection Intranasal or sublingual - as an alternative Intramuscular injection should be avoided in children In obese children, the dosage given should be based on ideal body weight

6. Paracetamol pre-op 20 mg / kg po (syrup) Post-op 15 mg / kg po á 6 hours. (30 mg / kg as a single dose rectally) maximum 24-hour dose 90mg/kg, followed by 50 mg / kg / d! from 3.months of age ! Watch out in hepatopathy Useful as a pre-emptive analgesic No effect on bleeding IV paracetamol (PERFALGAN) in hospitalised

7. NSAID - ibuprofen Pre-op - ibuprofen 10mg/kg p.o. (syrup) Post-op – if needed ibuprofen 5 mg/kg á 6-8 hod. p.o. Effective alone after oral and dental procedures. Can be used in conjunction with paracetamol. Have an opioid-sparing effect. Increase bleeding time due to inhibition of platelet aggregation. Useful analgesic once haemostasis has occurred. Best given if tolerating food and drink. Can be used in infants over 3 (some authors 6) months of age.

8. Non-steroidal anti-infl ammatory drugs (NSAIDs) NSAIDs are contraindicated in children with: Bleeding or coagulopathies. Renal disease. Haematological malignancies, who may have or develop thrombocytopenia. Asthma, especially if they are sensitive to asthma, steroid- dependent or have coexisting nasal polyps.

9. Sedation in paediatric dentistry The choice of a particular technique, sedative agent and route of delivery children’s responses are more unpredictable than adults - easily over-sedated Anatomical differences between the adult and the paediatric airways include: Children have a relatively larger tongue and epiglottis. Possible presence of large tonsillar/adenoid mass The mandible is less developed and retrognathic in children. Children have smaller lung capacity and reserve.

10. Patient assessment Medical and dental history (including medications taken). Patient medical status (American Society of Anaesthesiologists (ASA) classifi cation). History of recent respiratory symptoms or infections. Assessment of the airway to determine suitability for conscious sedation or general anaesthesia. Fasting status Procedure being performed Age Weight Parent factors

11. Inhalation sedation- nitrous oxide sedation Anxiolytic and mild analgesic effect Anxious but cooperating children Age - 4 years Benefits safe and relatively easy technique. light sedation. rapid onset (2-3min) and readily reversible with a short recovery time (10-15min) Entonox - titre fixed-N0 50%, 50% O2 requires only clinical monitoring

12. Contraindications Severe psychiatric disorders, mentaly handicaped Obstructive pulmonary disease Chronic obstructive airway disease Communication problems Uncooperating patients Pregnancy Acute respiratory tract infections Complications nausea, vomiting headache

13. Course of performance healthy child (no colds, cough and / or fever), not fasting, Entonox - inhalation using a face mask or mouthpiece. Maximum effect starts usually after 2-5min of uninterrupted inhalation Inhalation of Entonox continued intermittently throughout the performance (application of local anesthesia, tooth extraction, surgery). After treatment - child is kept under supervision in a room of about 5 to 10 minutes or until his attention and motor coordination are sufficiently restored

14. Conscious sedation patient who is awake, responsive and able to communicate maintenance of protective reflexes ! conscious sedation, deep sedation and/or general anaesthesia is a continuum Pulse oximetry Age and size-appropriate equipment and medications for resuscitation

15. Oral sedation Premedication Benzodiazepines (e.g. midazolam) Potentiated sedation– ANESTEZIOLOGIST Chloral hydrate Hydroxyzine Promethazine Ketamine

16. Midazolam - Dormicum short-acting benzodiazepine rapid patient recovery - extra sleep 2-3 hours dosage ranges from 0.3 mg - 0.7 mg / kg We 0.5 mg / kg P.o. Dormicum tablets 7.5 mg or Midazolam 1 ml amp effects: Sedative, hypnotic, anxiolytic, anterograde amnesia, myorelaxant

17. Course of performance The child must be healthy (no fever, cough, fever), Fasting for min. 3 hours (6hrs). With parent - short-term hospitalization, midazolam administered as a solution or tablets (0.5 mg/kg) under the supervision of accompanying person on a bed in sleep-room. onset of effect of midazolam - within 20-45 minutes the followed by dental procedures (tooth extraction / s, tooth decay treatment, surgery) Recovery period 2-3hrs - under the supervision of accompanying person on a bed in sleep-room.

18. Midazolam drugs given orally cannot be titrated accurately hepatic metabolism an overdose cannot be easily reversed oral sedation requires cooperation from the child to ingest the medication Never re-dose Per rectum - more reliable and controllable absorption, but requires cooperation, bad compliance Intranasal - whether the drug is absorbed directly from the blood stream or there is direct uptake to the central nervous system, requires a higher level of training and monitoring

19. Midazolam Intravenous sedation requires a highly trained team specialist anaesthetist monitoring, adequate facilities and recovery options controllable and may be readily reversible inappropriate form of drug administration in extremely anxious children IV sedation - in a hospital environment or accredited dental surgeries

20. Suitable procedures for midazolam sedation Short procedures that require approximately 30 minutes duration. Primary teeth extractions or up to two permanent molars. 1–2 quadrants of restorative dentistry. Short surgical procedures with good access in the mouth. not suitable for sedation 3–4 quadrants of restorative dentistry Extractions of permanent molars in each quadrant (invasive procedure and bleeding from all four quadrants make airway management more difficult). Obese children Parents who may not provide adequate care to the child postoperatively.

21. Midazolam - complications In rare cases, complications may occur in the form of so-called paradoxical reactions (manifested as tearfulness, hyperactivity, agitation, refusal to aggressive behavior) or vomiting. Symptoms of midazolam overdose can include: Ataxia Dysarthria Nystagmus Slurred speech Somnolence (difficulty staying awake) Mental confusion Hypotension Respiratory arrest Vasomotor collapse

22. Discharge criteria after sedation Self-maintenance of airway. Easily rousable and able to converse. No ataxia, can walk properly. Tolerating oral fl uids. Discharge in the care of a responsible adult with appropriate information about after-hours contact if a problem arises.