Conscious Sedation - Decision-making in the Borderline Cases

Sep 29, 2026

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Clinical guidance for pediatric dentistry focuses on when to use nonpharmacological behavior guidance, moderate or deep sedation, and general anesthesia. The work argues clinicians should not reserve moderate sedation only for children already showing hysterical behavior and emphasizes predictable selection of behavior management modes. Successful implementation depends on accurately classifying behavior on the dental chair using Frankl’s behavior rating scale and determining planned procedure length, then choosing an appropriate strategy grounded in scientific fundamentals.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages4

Reading Time10 min

AccessFree to download

Aim

Background

Technique

Conclusion

Background

Definition and rationale for moderate sedation

Decision-making based on behavior classification

REVIEW ARTICLE Conscious Sedation: Decision-making in the Borderline Cases Ashwin Rao1, Steven JL Rodrigues2, Sivakumar Nuvvula3, Nikhil Marwah4, Anup K Panda5, Makkada Yuvaraj Padmanabhan6, Sharath Asokan7, Srinivas Namineni8, Sukhdeep Singh9, Sreekanth K Mallineni10 Received on: 19 March 2025; Accepted on: 20 August 2025; Published on: 05 November 2025 aBstract Aim: This article is intended to aid clinicians in deciding on the use of nonpharmacological behavior guidance, moderate or deep sedation, and general anesthesia. Background: Very often, clinicians are hesitant to use moderate sedation till the child is already displaying hysterical behavior. Moderate sedation is not intended to be used on a child displaying hysterical behavior. The clinician should be able to predictably and confidently decide on the use of various modes of child management for the presenting child behavior. Technique: To successfully implement child management strategies, the clinician should be able to accurately classify the child’s behavior on the dental chair using Frankl’s behavior rating scale. The clinician should also classify the length of the procedure intended. Based on these two criteria, the clinician can choose the appropriate behavior management strategy. Conclusion: The appropriate behavior guidance technique should not be arbitrary. It should be based on sound fundamentals of scientific knowledge. Keywords: Conscious sedation, Frankl behavior rating, Inhalation sedation, Minimal sedation, Moderate sedation, Oral midazolam. International Journal of Clinical Pediatric Dentistry (2025): 10.5005/jp-journals-10005-3328 Background The literature on sedation in Pediatric Dentistry commonly includes study subjects in whom “basic behavior modification tools have been unsuccessful”.1 There are nowell-defined inclusion criteria or characteristics qualifying the children for the study. This leads to a clinical situation where the sedation outcomes could be unpredictable, and the conclusions could be biased. We hypothesized that accurately classifying the behavior of children using any known behavior rating scales2, 3 could help the clinician rationally choose appropriate cases for nonpharmacological guidance and pharmacological guidance, respectively. This “Clinical Technique” article will primarily discuss decision-making on when to use nonpharmacological guidance and when to use moderate sedation. It will further elaborate on when to use deep sedation and general anesthesia. It is important to understand, under this context, that nonpharmacological management and moderate sedation go hand in hand. In order to understand this concept, we need to first understand moderate sedation. Moderate sedation (old terminology,“conscious sedation” or “sedation/ analgesia”) is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands or after light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. The caveat that loss of consciousness should be unlikely is a particularly important aspect of the definition of moderate sedation; drugs and techniques used should carry a margin of safety wide enough to render unintended loss of consciousness unlikely.4 This definition clearly implies that in moderate sedation, the drugs that are used will not, on their own, be able to overcome the child’s resistance. So, essentially, that means moderate sedation should not be used to overcome resistance in a child displaying combative behavior. It is most effective in anxious children who are willing to cooperate. Since, by definition, 1Department of Pediatric and Preventive Dentistry, Manipal College of Dental Sciences, Mangaluru, Manipal Academy of Higher Education, Manipal, Karnataka, India 2Department of Pediatric and Preventive Dentistry, Government Dental College & Hospital, Pana

FAQs

What is the article’s primary aim for clinicians?

To help clinicians decide when to use nonpharmacological behavior guidance, moderate or deep sedation, and general anesthesia.

Why should moderate sedation not be used in certain behavioral presentations?

Moderate sedation is not intended to be used when a child is displaying hysterical behavior, because it cannot be used to overcome a child’s resistance in combative behavior.

How should clinicians choose the appropriate behavior management strategy?

By accurately classifying the child’s behavior using Frankl’s behavior rating scale and also classifying the length of the intended procedure, then selecting the suitable strategy accordingly.

Sep 29, 2026

Upload by jayni