A Comparative Evaluation of Agents Producing Analgo-sedation in Pediatric Dental Patients.

Objective: Procedural sedation and analgesia (PSA) has reduced the need for general anesthesia (GA) for many surgical procedures in pediatric patients. The objective of this study was to evaluate the efficacy of four analgo-sedative combinations- midazolam plus ketamine (MK), midazolam plus tramadol (MT),promethazine plus tramadol (PT) and promethazine plus ketamine (PK) in facilitating dental treatment of uncooperative children. Study design: Thirty six uncooperative ASA type I children who required extensive dental treatment were randomly assigned to receive one of the four analgo-sedative combinations during each visit. A 4-stage cross-over design was adopted so that each child received all the four combinations. Safety was monitored through vital signs and side effects. Results: The overall success was 81% with MK,69% for PK, 67% for MT and 42% for PT and the difference between the success rates of these agents was statistically significant (p < 0.001). The required dental treatment could be successfully completed at least during 3 sessions in 23 children (62.2%). Conclusions: Segmental dental treatment under analgo-sedation can be considered as a viable alternative before considering patients for dental management under GA. MK and MT were found to be safe and effective for sedating pediatric dental patients.

sedation, analgesia, procedural sedation and analgesia, analgo-sedation, midazolam, ketamine, promethazine, tramadol

1. Kaplan RF, Yang CI. Sedation and analgesia in pediatric patients for procedures outside the operating room. Anesthesiol Clin North Amer-ica, 20(1): 181–94, 2002.

2. Pitetti RD, Singh S, Pierce MC. Safe and efficacious use of procedural sedation and analgesia by nonanesthesiologists in a pediatric emer-gency department. Arch Pediatr Adolesc Med, 157(11): 1090–6, 2003.

3. Doyle L, Colletti JE. Pediatric procedural sedation and analgesia. Pedi-atr Clin North Am, 53(2): 279–92, 2006.

4. Nathan JE, Vargas KG. Oral midazolam with and without meperidine for management of the difficult young pediatric dental patient: a retro-spective study. Pediatr Dent, 24(2): 129–38, 2002.

5. Kupietzky A, Houpt MI. Midazolam: a review of its use for conscious sedation of children. Pediatr Dent, 15(4): 237-41, 1993.

6. Nikolajsen L, Hansen PO, Jensen TS. Oral ketamine therapy in the treatment of postamputation stump pain. Acta Anaesthesiol Scand, 41(3): 427–9, 1997.

7. Ugur F, Gulcu N, Boyaci A. Oral ketamine for pain relief in a child with abdominal malignancy. Pain Med, 10(1): 120–1, 2009.

8. Roelofse JA, Joubert JJ, and Roelofse PG. A double-blind randomized comparison of midazolam alone and midazolam combined with keta-mine for sedation of pediatric dental patients. J Oral Maxillofac Surg, 54(7): 838–44, 1996.

9. Reich DL, Silvay G. Ketamine: an update on the first twenty-five years of clinical experience. Can J Anaesth, 36(2): 186–97, 1989.

10 Craven R. Ketamine. Anaesthesia, 62 Suppl 1:48–53, 2007.

11. White PF, Way WL, Trevor AJ. Ketamine—its pharmacology and ther-apeutic uses. Anesthesiology, 56(2): 119–36, 1982.

12. Barclay A, Houlton PC, Downing JW. Total intravenous anaesthesia: a technique using flunitrazepam, ketamine, muscle relaxants and con-trolled ventilation of the lung. Anaesthesia, 35(3): 287–90, 1980.

13. Lokken P, Bakstad OJ, Fonnelop E et al. Conscious sedation by rectal administration of midazolam or midazolam plus ketamine as alterna-tives to general anesthesia for dental treatment of uncooperative chil-dren. Scand J Dent Res, 102(5): 274–80, 1994.

14. Bui T, Redden RJ, Murphy S. A comparison study between ketamine and ketamine-promethazine combination for oral sedation in pediatric dental patients. Anesth Prog, 49(1): 14–8, 2002.

15. Alfke H, Reuter P, Wagner HJ, Bohme K. The premedication of PTA. A double-blind and randomized comparison of midazolam/tramadol versus placebo/tramadol. Rofo, 159(5): 461–6, 1993

16. Ahmed A, Khan FA, Hussain A. Comparison of two sedation tech-niques in patients undergoing surgical procedures under regional anaesthesia. J Pak Med Assoc, 57(11): 548–52, 2007.

17. Koirala B, Pandey RK, Saksen AK, Kumar R, Sharma S. A compara-tive evaluation of newer sedatives in conscious sedation. J Clin Pediatr Dent, 30(4): 273–6, 2006.

18. Singh N, Pandey RK, Saksena AK, Jaiswal JN. A comparative evalua-tion of oral midazolam with other sedatives as premedication in pedi-atric dentistry. J Clin Pediatr Dent, 26(2): 161–4, 2002.

19. American Academy of Pediatrics; American Academy of Pediatric Dentistry, Coté CJ, Wilson S; Work Group on Sedation. Guidelines for monitoring and management of pediatric patients during and after seda-tion for diagnostic and therapeutic procedures: an update. Pediatrics, 118(6): 2587–602, 2006.

20. Citerio G, Franzosi MG, Latini R. Anaesthesiological strategies in elec-tive craniotomy: randomized, equivalence, open trial—the NeuroMor-feo trial. Trials, Apr;10:19, 2009.

21. Roelofse JA, Payne KA. Oral tramadol: analgesic efficacy in children following multiple dental extractions. Eur J Anaesthesiol, 16(7): 441–7, 1999.

22. Mattia C, Coluzzi F. Tramadol. Focus on musculoskeletal and neuro-pathic pain. Minerva Anestesiol, 71(10): 565–84, 2005.

23. Grond S, Sablotzki A. Clinical pharmacology of tramadol. Clin Phar-macokinet, 43(13): 879–923, 2004.

24. Lawrence S, McTigue DJ, Wilson S, Odom JG, Waggoner WF, Fields HW. Parental attitudes toward behavior management techniques used in pediatric dentistry, Pediatr Dent, 13: 151–155, 1991.