AAPD GUIDELINES & RELEVANT
PEDIATRIC DENTISTRY READINGS
EXAM
diminution or elimination of pain and anxiety in a conscious patient. The patient
responds normally to verbal commands. All vital signs are stable, there is no significant
risk of losing protective reflexes, and the patient is able to return to preprocedure
mobility. - Correct Answers -analgesia/ anxiolysis (AAPD 204)
What affect does nitrous oxide have on the CNS? - Correct Answers -causes
depression and euphoria (AAPD 204)
Nitrous oxide has two mechanisms of action. Describe MOA that creates the analgesic
effect and the MOA that creates the anxiolytic effect. - Correct Answers -Analgesic
effect: "appears to be initiated by neuronal release of endogeneous opioid peptides with
subsequent activation of opioid receptors and descending Gamma-amniobutyric acid
type A (GABBA) receptors and noradrenergic pathways that modulate nociceptive
processing at the spinal level"
Anxiolytic effect: "activation of the GABAA receptor either directly or indirectly through
the benzodiazepine binding site" (AAPD 204)
Describe the solubility of nitrous oxide - Correct Answers -Although the AAPD describes
nitrous as 34 times more soluble than nitrogen; nitrous is relatively insoluble which is
the reason it can quickly diffuse in and out of the human body/blood. (AAPD 204)
Describe the effect of nitrous on the cardiovascular system? (Include effect on cardiac
output, peripheral resistance and blood pressure) - Correct Answers -Nitrous oxide
causes minor depression in cardiac output while peripheral resistance is slightly
increased, thereby maintaining the blood pressure. (AAPD 204)
How rapid is Nitrous Oxide recovery - Correct Answers -two to three minutes (AAPD
204)
What is the effect of Nitrous Oxide on the cough reflex? - Correct Answers -Minimal
impairment to any reflex including the cough reflex (cough reflex is preserved) (AAPD
204)
,The most common adverse effects of nitrous oxide are nausea and vomiting which
occur in what percentage of patients? - Correct Answers -0.5 percent; a higher
incidence is noted with longer administration of nitrous oxide/oxygen, fluctuation sin
nitrous oxide levels, and increased concentrations of nitrous oxide (AAPD 206)
According to the study by Leelataweewud in 2000, what were the relevant effects of
incorporating N2O/O2 to a conscious sedation of 1.5 mg/kg meperidine (demerol)
(narcotic sedative), 50 mg/kg chloral hydrate and 25 mg hydroxyzine pamoate vs. that
same triple cocktail with just O2? - Correct Answers -1) No differences in pulse rate,
oxyhemoglobin saturation (did find small increase in respiratory rate in N2O/O2 group)
2) N2O/O2 did not increase risk of desaturation but did increase frequency of
desaturation events
3) N2O/O2 deepened level of sedation (so can deepen when added to a narcotic
sedation regimen)
4) if you are going to include N2O/O2 - must monitor with heightened vigilance
What is the nonselective, competitive, alpha-adrenergic antagonist used to reverse the
effects of adrenergic agonists like epinephrine? - Correct Answers -phentolamine
mesylate
What is the proposed mechanism of action for phentolamine mesylate with respect to
local anesthesia reversal - Correct Answers -phentolamine mesylate is a vasodilator
and the increased local blood flow accelerates the clearance of local anesthetic from the
submucosal tissue to the bloodstream
T/F Injection of phentolamine mesylate at the same site as the local anesthetic was
injected can cut the time to return of normal lip sensation and normal tongue sensation
in half - Correct Answers -true: "We observed a 55.6 percent reduction in median time
to return of normal lip sensation and a 60 percent reduction in median time to return of
normal tongue sensation (Tavares JADA 2008)
Which are better at suppressing awareness? A) Potent inhaled vapors, midazolam
(versed), propofol
B) nitrous oxide and opioids - Correct Answers -A) Potent inhaled vapors, midazolam
(versed), propofol
In the study by Watts et al. what was the effect of giving local anesthesia during a
general anesthesia case on vital signs vs. no local anesthesia - Correct Answers
-"Patients who were not given intraoperative local anesthesia were more likely to
experience vital sign fluctuation requiring anesthesiologist intervention" (Watts, Pediatric
dentistry, 2009)
A drug-induced depression of consciousness during which patients respond
purposefully to verbal commands either alone or accompanied by light tactile
stimulation. For older patients, this level of sedation implies an interactive state; for
younger patients, age-appropriate behaviors like crying occur and are expected. Reflex
, withdrawal is accompanied by a purposeful response (like pushing away). No
intervention required to maintain a patent airway, spontaneous ventilation is adequate.
Cardiovascular function is usually maintained. - Correct Answers -Moderate sedation
(old terminology = "conscious sedation" or "sedation/analgesia") (AAPD 210)
Drug induced state during which patients respond normally to verbal commands.
Although cognitive function and coordination may be impaired, ventilatory and
cardiovascular functions are unaffected - Correct Answers -Minimal sedation (old
terminology "anxiolysis") (AAPD 210)
A drug-induced depression of consciousness during which patients cannot be easily
aroused but respond purposefully after repeated verbal or painful stimulation (eg
pushing away noxious stimuli). Ability to independently maintain ventilatory function may
be impaired. Patients may require assistance in maintaining a patent airway, and
spontaneous ventilation may be inadequate. Cardiovascular function is usually
maintained. May be accompanied by partial or complete loss of protective airway
reflexes - Correct Answers -Deep sedation (old terminology "deep sedation/analgesia")
(AAPD 210)
A drug-induced loss of consciousness during which patients are not arousable, even by
painful stimulation. Ability to independently maintain ventilatory function is often
impaired. Patients often require assistance in maintaining a patent airway and positive-
pressure ventilation may be required because of depressed spontaneous ventilation or
drug induced depression of neuromuscular function. Cardiovascular function may be
impaired. - Correct Answers -General anesthesia (AAPD 211)
What class of drug is pentobarbital? - Correct Answers -pentobarbital is a barbituate;
has a long duration of action when given in the intramuscular form (AAPD 211)
Why do drugs like chloral hydrate, intramuscular pentobarbital and phenothiazines
require longer periods of observation even after the child achieves currently used
recovery and discharge criteria? - Correct Answers -These drugs have a long duration
of action. Important for children transported in car seats as there is a risk of resedation
after discharge and potential airway obstruction AAPD 211)
Describe the increased risk involved with a toddler or infant who is transported via car
safety seat after sedation with chloral hydrate, intramuscular pentobarbital and/or
phenothiazines - Correct Answers -risk of resedation after discharge and potential
airway obstruction as these medications have a long half-life (AAPD 212)
T/F It is permissible for routine necessary medications to be taken with a sip of water on
the day of the sedation procedure - Correct Answers -true (AAPD 212)
Through what mechanism to St. John's wort and echinacea alter drug
pharmacokinetics? - Correct Answers -Though inhibition of the cytochrome P450
PEDIATRIC DENTISTRY READINGS
EXAM
diminution or elimination of pain and anxiety in a conscious patient. The patient
responds normally to verbal commands. All vital signs are stable, there is no significant
risk of losing protective reflexes, and the patient is able to return to preprocedure
mobility. - Correct Answers -analgesia/ anxiolysis (AAPD 204)
What affect does nitrous oxide have on the CNS? - Correct Answers -causes
depression and euphoria (AAPD 204)
Nitrous oxide has two mechanisms of action. Describe MOA that creates the analgesic
effect and the MOA that creates the anxiolytic effect. - Correct Answers -Analgesic
effect: "appears to be initiated by neuronal release of endogeneous opioid peptides with
subsequent activation of opioid receptors and descending Gamma-amniobutyric acid
type A (GABBA) receptors and noradrenergic pathways that modulate nociceptive
processing at the spinal level"
Anxiolytic effect: "activation of the GABAA receptor either directly or indirectly through
the benzodiazepine binding site" (AAPD 204)
Describe the solubility of nitrous oxide - Correct Answers -Although the AAPD describes
nitrous as 34 times more soluble than nitrogen; nitrous is relatively insoluble which is
the reason it can quickly diffuse in and out of the human body/blood. (AAPD 204)
Describe the effect of nitrous on the cardiovascular system? (Include effect on cardiac
output, peripheral resistance and blood pressure) - Correct Answers -Nitrous oxide
causes minor depression in cardiac output while peripheral resistance is slightly
increased, thereby maintaining the blood pressure. (AAPD 204)
How rapid is Nitrous Oxide recovery - Correct Answers -two to three minutes (AAPD
204)
What is the effect of Nitrous Oxide on the cough reflex? - Correct Answers -Minimal
impairment to any reflex including the cough reflex (cough reflex is preserved) (AAPD
204)
,The most common adverse effects of nitrous oxide are nausea and vomiting which
occur in what percentage of patients? - Correct Answers -0.5 percent; a higher
incidence is noted with longer administration of nitrous oxide/oxygen, fluctuation sin
nitrous oxide levels, and increased concentrations of nitrous oxide (AAPD 206)
According to the study by Leelataweewud in 2000, what were the relevant effects of
incorporating N2O/O2 to a conscious sedation of 1.5 mg/kg meperidine (demerol)
(narcotic sedative), 50 mg/kg chloral hydrate and 25 mg hydroxyzine pamoate vs. that
same triple cocktail with just O2? - Correct Answers -1) No differences in pulse rate,
oxyhemoglobin saturation (did find small increase in respiratory rate in N2O/O2 group)
2) N2O/O2 did not increase risk of desaturation but did increase frequency of
desaturation events
3) N2O/O2 deepened level of sedation (so can deepen when added to a narcotic
sedation regimen)
4) if you are going to include N2O/O2 - must monitor with heightened vigilance
What is the nonselective, competitive, alpha-adrenergic antagonist used to reverse the
effects of adrenergic agonists like epinephrine? - Correct Answers -phentolamine
mesylate
What is the proposed mechanism of action for phentolamine mesylate with respect to
local anesthesia reversal - Correct Answers -phentolamine mesylate is a vasodilator
and the increased local blood flow accelerates the clearance of local anesthetic from the
submucosal tissue to the bloodstream
T/F Injection of phentolamine mesylate at the same site as the local anesthetic was
injected can cut the time to return of normal lip sensation and normal tongue sensation
in half - Correct Answers -true: "We observed a 55.6 percent reduction in median time
to return of normal lip sensation and a 60 percent reduction in median time to return of
normal tongue sensation (Tavares JADA 2008)
Which are better at suppressing awareness? A) Potent inhaled vapors, midazolam
(versed), propofol
B) nitrous oxide and opioids - Correct Answers -A) Potent inhaled vapors, midazolam
(versed), propofol
In the study by Watts et al. what was the effect of giving local anesthesia during a
general anesthesia case on vital signs vs. no local anesthesia - Correct Answers
-"Patients who were not given intraoperative local anesthesia were more likely to
experience vital sign fluctuation requiring anesthesiologist intervention" (Watts, Pediatric
dentistry, 2009)
A drug-induced depression of consciousness during which patients respond
purposefully to verbal commands either alone or accompanied by light tactile
stimulation. For older patients, this level of sedation implies an interactive state; for
younger patients, age-appropriate behaviors like crying occur and are expected. Reflex
, withdrawal is accompanied by a purposeful response (like pushing away). No
intervention required to maintain a patent airway, spontaneous ventilation is adequate.
Cardiovascular function is usually maintained. - Correct Answers -Moderate sedation
(old terminology = "conscious sedation" or "sedation/analgesia") (AAPD 210)
Drug induced state during which patients respond normally to verbal commands.
Although cognitive function and coordination may be impaired, ventilatory and
cardiovascular functions are unaffected - Correct Answers -Minimal sedation (old
terminology "anxiolysis") (AAPD 210)
A drug-induced depression of consciousness during which patients cannot be easily
aroused but respond purposefully after repeated verbal or painful stimulation (eg
pushing away noxious stimuli). Ability to independently maintain ventilatory function may
be impaired. Patients may require assistance in maintaining a patent airway, and
spontaneous ventilation may be inadequate. Cardiovascular function is usually
maintained. May be accompanied by partial or complete loss of protective airway
reflexes - Correct Answers -Deep sedation (old terminology "deep sedation/analgesia")
(AAPD 210)
A drug-induced loss of consciousness during which patients are not arousable, even by
painful stimulation. Ability to independently maintain ventilatory function is often
impaired. Patients often require assistance in maintaining a patent airway and positive-
pressure ventilation may be required because of depressed spontaneous ventilation or
drug induced depression of neuromuscular function. Cardiovascular function may be
impaired. - Correct Answers -General anesthesia (AAPD 211)
What class of drug is pentobarbital? - Correct Answers -pentobarbital is a barbituate;
has a long duration of action when given in the intramuscular form (AAPD 211)
Why do drugs like chloral hydrate, intramuscular pentobarbital and phenothiazines
require longer periods of observation even after the child achieves currently used
recovery and discharge criteria? - Correct Answers -These drugs have a long duration
of action. Important for children transported in car seats as there is a risk of resedation
after discharge and potential airway obstruction AAPD 211)
Describe the increased risk involved with a toddler or infant who is transported via car
safety seat after sedation with chloral hydrate, intramuscular pentobarbital and/or
phenothiazines - Correct Answers -risk of resedation after discharge and potential
airway obstruction as these medications have a long half-life (AAPD 212)
T/F It is permissible for routine necessary medications to be taken with a sip of water on
the day of the sedation procedure - Correct Answers -true (AAPD 212)
Through what mechanism to St. John's wort and echinacea alter drug
pharmacokinetics? - Correct Answers -Though inhibition of the cytochrome P450
