– Any discussion of child management in dentistry is incomplete without the inclusion of
pharmacological methods such as conscious sedation, deep sedation and general
– These methods do not replace the non-pharmacological methods in any way but are useful when the behavior modification is either not feasible or has failed.
– Dentistry and anesthesiology have been interestingly termed as ‘strange bedfellows’!
– The first use of a general anesthetic, nitrous oxide, was meant for a dental procedure carried out by a dentist (Horace Wells).
– The first anesthesia machine was also developed by a dentist (Charles Teter).
– In the Western world, various sedation techniques for child management are routinely p
racticed by dentists trained in ‘dental anesthesiology’. However, in India, the use of
sedation and general anesthesia for dental treatments is neither widely taught nor
practiced much for various reasons.
– Decision-making of pharmacological management is a skill that is not easy to acquire.
– Often, a dentist may decide to treat the child under general anesthesia while examining
a 3-4 year child patient who is not willing to get teeth checked in a dental chair.
–On the other hand, he/she may over-attempt behavior modification just to avoid the
– To a certain extent, it is the bias developed in the dentist’s mind due to a previously failed
behavior modification in a child that compels a dentist to consider the option of managing a child pharmacologically in haste.
– The parental demands may have an influence on the dentist’s decision to choose the child management method.
– Some parents may be too apprehensive about the risks involved in the pharmacological way; whereas, some may not easily agree to voice intonation or methods like aversive
– Even the best and experienced practitioners of Behavioral Pedodontics would agree that
behavior modification has its limitations in spite of its high success, predictability and
– Some of the limitations are as follows:
1. Behavior modification requires patience on the part of both the dentist and parents.
It is actually not time consuming because, once the child becomes cooperative, usually a lot of treatment can be carried out (for example, quadrant dentistry) in a single visit that makes up for the time spent initially on bringing about behavior modification in the child.
However, a pharmacological method such as general anesthesia may allow even full mouth rehabilitation in a single visit, the same with behavior modification is almost impossible.
The dentist as well as the parents must sustain interest in the child’s treatment that may take multiple visits and may encounter an occasional behavior management failure
(such as a child crying on the day of a tooth extraction, while remaining cooperative through other treatments).
2. Emergency treatments are difficult to carry out on day one or during initial visits with only behavior modification.
Often, resorting to behavior modification techniques such as voice intonation and aversive conditioning may help render the early emergency care, but in the process if the child
experiences dentistry negatively, further child management becomes an arduous task.
3. Children coming from a long distance, children reporting less frequently (each appointment more than a week apart), children seeking late evening appointments are difficult
candidates for behavior modification. Also, it is a challenge for a pediatric dentist ‘visiting’
a certain clinic once a week or once in a fortnight, to bring about behavior modification
in a child.
4. The ‘protocol’ system of child management that outlines the treatment plan and the
treatment schedule in view of child cooperation as well as various behavior modification methods must be well understood and endorsed by the parents before the actual
treatment begins. At times, specific concerns of parents pose a problem for the dentist to sort out; for example, the dentist wishes to carry out the treatment in a sequenced manner with fluoride application and small restorations in the beginning and treatments
like extractions of asymptomatic anterior teeth later. However, the parents may be
concerned about the ugly appearance of the anterior teeth and insist on them being treated first. Such demands disturb the ‘protocol’ and pose difficulties in child
5. All children are not the same even if they are of the same age, society or even a family.
It may not always be possible to highly individualize behavior modification techniques to suit each and every child’s demands. Also, a practitioner may not be good at all techniques and usually practices a behavior modification technique in a certain ‘stereotype’ manner. For example, two practitioners may be using different communication styles while
administering local anesthesia effectively; but in the event of failure (for any one of them), to adopt the other person’s communication style is not easy.
6. It is not possible to modify child behavior when the dentist feels angry or is tired (or is not in a happy mood); wants to finish work early or is already late in the schedule. Such emotional as well as practical problems come into play in day-to-day practice.
7. Some failures are just simple statistics. They do not require any explanations. Just as the same antibiotic does not work for the same infection in all individuals; the methods that are well documented, time tested and proven beyond doubt can also fail at times.
– The detailed account of pharmacological management is beyond the scope of this discussion.
– The pharmacological management may be recommended to parents at any of the following situations:
1. Before beginning the treatment (Just after consultation)
2. After initial visits
3. In the event of failed/inadequate behavior modification
– The dentist may have to choose the option of recommending the pharmacological
management considering various indicating factors.
– The same are listed below:
When to recommend
Before beginning the treatment
(Just after consultation)
• Too young children (< 2 years, requiring complicated work like pulp therapy)
• Emergency (trauma, space infections with limitation in opening mouth)
• Severe physical/mental disability; underlying medical condition
• Specific demand of parents due to previous negative experience of the child
After initial visits
• If behavior modification not successful, or parents object to certain means
• If an emergency develops, for the management of which the child is not ready yet
• A problem like severe gagging tendency that hinders treatment
In the event of failed/inadequate behavior modification
• A child failing to get accustomed, consistently un-cooperative in spite of all attempts
– The two obvious advantages of the pharmacological child management are:
1. No ‘cooperation’ factor: no movements of child’s head, tongue, body, no saliva
contamination or gagging, no need for the dentist to remain in active conversation with the child.
2. It is possible to complete extensive procedures in single/fewer visits.
The decision of pharmacological management eliminates the need for extensive thinking and application of behavior modification techniques for the dentist. At times, even the
parents find this modality more practical. The advantages of pharmacological methods, however, come with a statistically very small but significant risk.
Are the pharmacological methods easily accepted by parents?
– Whenever the option of general anesthesia or sedation in a hospital environment is
recommended to the parents, they first fear the worst! Their fear is not entirely unfounded.
– It is not an easy decision to make for any parent. The dentist now has to undertake the
responsibility of answering a lot of questions to the parents to their satisfaction.
– Also, the dentist should not try to influence their decision, but only tell them in a professional manner the necessity of pharmacological method.
– The final decision has to be an unbiased decision of the child’s legal guardians.
– The dentist, however, must tell the parents that the other methods of treating the child have either failed or are not applicable for the dental management of their child.
– The dentist has to stress upon the fact that modern anesthesia is considered safe and only because of certain advances in the field of anesthesiology and dentistry, the treatment of critical conditions (such as severe early childhood caries with acute dental conditions like abscesses) is possible.
– The dentist also should point out to them his/her own safety record and past experience.
– The parents must also be encouraged to speak to the anesthesiologist and satisfy themselves regarding the facilities in the hospital before the treatment is scheduled.
– The ultimate aim of child management in dentistry is to deliver high quality dental care for the child in a comfortable manner while instilling him/her a positive attitude towards
– The author always prefers to explore all possibilities of child management with behavior
modification prior to considering the option of pharmacological methods.