Sedation in Uncooperative Children Undergoing Dental Procedures: A Comparative Evaluation of Midazolam, Propofol and Ketamine.

Dentists usually face a common problem dealing with pediatric patients due to their high levels of anxiety and fear, associated with dental procedures. Such children are usually managed by various pharmacological methods. The efficacy and safety of conscious sedation, using intravenous short acting group of drugs(midazolam, propofol and ketamine ) in uncooperative children, requiring oral rehabilitation was thus evaluated in this study. A total of 30 uncooperative children, aged 3-6 years, belonging to ASA I, II category formed the study group. The efficacy of the three group of drugs was evaluated on the basis of the onset of sedation, duration of action, side effects encountered, and the overall cooperative behavior of the child throughout the course of the procedure, after obtaining parental consent. Results showed that propofol was highly effective in terms of onset of sedation, although increased body movements and crying, pain on injection and intermittent cough was observed as the main side effects of the drug. Midazolam showed the longest duration of action, but was not very effective in terms of treatment completion due to increased movements and crying. Maximum cooperation during the procedure was obtained with ketamine and no adverse effects were encountered. We preferred ketamine from the results of our study and recommended future evaluation of ketamine in combination with other sedatives.

conscious sedation, uncooperative children, midazolam, propofol, ketamine

1. Singh N, Pandey RK, Saksena AK, Jaiswal JN. A comparative evalua-tion of oral midazolam with other sedatives as premediation in pediatric dentistry. J Clin Pediatr Dent 26(2): 161–64, 2002.

2. Veerkamp JSJ, Porcelijn T, Gruythuysen R. Intravenous sedation for outpatient treatment of child dental patients: an exploratory study. J Dent Child 48–54, 1997.

3. Raymoud A. Dionne, John A. Yagiela, Paul A. Moore, Arthur Gonty, John Zuniga, Ross Beirne: Comparing efficacy and safey of four intra-venous sedation regimens in dental outpatients. JADA (132); 740–51, 2001.

4. Giovanti JA. Midazolam: review of a versatile agent for use in dentistry. Anesth Prog 34: 64–70, 1987.

5. Payne K, Mattheyse FJ, Liebenberg D, Dawes T: Pharmacokinetics of midazolam in pediatric patients. European J. Clin Pharmocol 37; 267–72, 1989.

6. Kay B and Rolly G: I.C.I. 35868, a new intravenous induction agent. Acta Anaesthesiol Belg 28: 303–16, 1977.

7. Kalpan S and Hirschowitz AS. The dental treatment of problem children under ketamine analgesia. S Afr J 49: 313–14, 1975.

8. George A. Gregory: Pediatric Anesthesia, 3rd edition Churchill Living-stone, p. 184-6.

9. Houpt M: Project USAP the use of sedative agents in pediatric dentistry. Pediatr Dent 15(1): 36–40, 1993.

10. Sidney B. Finn: Clinical Pedodontics. 4th ed, 1991, p 114.

11. Worthigton LM, Flyn PJ, Strunin: Death in the dental; chair: An avoid-able catastrophe? Br J Anaesth 80: 131–132, 1998.

12. Shaw AJ: The use of inhalation sedation and local aesthesia instead of general anesthesia for extraction of minor oral surgery in children: A prospective study. Int J Paediatr Dent 6: 7–11, 1996.

13. Nathan JE: oral conscious sedation for the pediatric dental patient. Pedi-atr Dent 4: 1–7, 1991.

14. Kupietzky A: Strap him down or knock him out : Is conscious sedation with restraint an alternative to general anesthesia? Brit Dent J 196(3): 133–8, 2004.

15. Parworth LP, Frost DE, Zuniga JR, Bennett T: Propofol and Fentanyl compared with Midazolam and Fentanyl during third molar surgery. J Oral Maxillofac Surg 57(2): 219, 1999.

16. Godambe S, Elliot V, Matheny D, Pershad J: Comparison of Propofol/Fentanyl versus Ketamine / Midazolam for brief Orthopedic procedural sedation in a pediatric Emergency Department. Pediatr 15(6): 116–23, 2003.

17. Seigler RS, Avant MG, Gwyn DR. Lynch AL, Golding EM, Blackhurst DW: a comparison of propofol and ketamine/ midazolam for intra-venous sedation of children. Pediatric Crit Care Med 2(1): 20–3, 2001.

18. Vardi A, Salem Y, Padeh S, Paret G, Barzilay Z: Is propofol safe for pro-cedural sedation in children? Crit Care Med 30(6): 1231–6, 2002.

19. Ostreikov IF, Vasil’ev IAI, MIlenin VV, Pivovarov SA, Babaev BD:clin-ical picture of awaking after general anesthesia with midazolam, propo-fol ketamine and fluothane in children treated at one day ambulatory faculty. Anesteziol Reanimatol 1: 36–8, 2001.

20. Bennett J, Shafer DM, Efaw, Goupil M: Incremental bolus versus a con-tinuous infusion of propofol for deep sedation/ general anesthesia dur-ing dento alveolar surgery. J Oral Maxillofac Surgery 56(9): 1049–53, 1998.

21. Tamminga GY, Armbrust W, Kamps WA: Midazolam compared with ketamine for invasive procedures. Pediatr Hematol Oncol 21(1): 93–4, 2004.