Pediatrician’s knowledge, perception and awareness regarding sedation in pediatric dentistry: a questionnaire-based survey

INTRODUCTION

Oral health is a crucial aspect of overall health and well-being in children. Dental illnesses, especially early childhood caries, continue to be among the most common chronic conditions impacting pediatric population globally.¹ The consequences of ECC include a higher risk of new caries lesions in both the primary and permanent dentitions, hospitalizations and emergency room visits, high treatment costs, loss of school days, diminished ability to learn, nutritional deficiencies and reduced oral health-related quality of life in addition to its physical repercussions.² Therefore, timely diagnosis and appropriate dental management are crucial for maintaining optimal health during childhood.

However, providing dental treatment to children, is often challenging because of fear, anxiety, immature cognitive development and limited ability to cooperate during procedures.³ Younger children may be unable to comprehend the need for treatment, while those with previous negative experiences can exhibit marked dental anxiety.⁴ Children with special healthcare needs or certain medical conditions may present additional behavioral and management difficulties. Consequently, successful pediatric dental care requires effective behavior guidance strategies to ensure safe, efficient and high-quality treatment.⁵

The number of diagnostic and minor surgical procedures performed on pediatric patients outside of the traditional operating room setting has increased in the past several decades. As a consequence of this change and the increased awareness of the importance of providing analgesia and anxiolysis, the need for sedation for procedures in physician’s offices, dental offices, subspecialty procedure suites, imaging facilities, emergency departments, other inpatient hospital settings and ambulatory surgery centers also has increased markedly.⁶

Behavior guidance in Pediatric Dentistry includes both non-pharmacological and pharmacological methods. Conventional non-pharmacological techniques such as tell-show-do, positive reinforcement, distraction and parental counselling are routinely employed.⁵ However, these techniques may not always be sufficient in highly anxious, pre-cooperative or medically compromised children. In such circumstances, pharmacological approaches such as sedation and general anesthesia become valuable adjuncts. Sedation helps reduce anxiety, control movement, increase cooperation and facilitate the completion of dental procedures while maintaining patient safety and comfort.⁷

Sedation in Pediatric Dentistry may range from minimal sedation to moderate sedation and in selected cases, deep sedation depending on the child’s age, behavior, medical status and treatment requirements.⁸ Commonly used techniques include nitrous oxide/oxygen inhalation sedation and the use of oral, intranasal or intravenous sedative agents such as midazolam or ketamine under appropriate monitoring protocols.⁹ When administered by trained personnel following established guidelines, sedation has been shown to be a safe and effective modality that improves treatment acceptance and minimizes psychological trauma associated with dental care.

Pediatricians play a major role in the comprehensive healthcare of children and are often the first professionals consulted by parents regarding developmental, medical and behavioral concerns.¹⁰ Since they maintain long-term contact with families from infancy onward, they are in an ideal position to guide preventive practices and facilitate referrals to other specialists, including pediatric dentists.¹¹ Parents frequently seek reassurance from pediatricians regarding dental treatment, pain control, anesthesia and sedation before consenting to procedures.¹² Therefore, pediatrician’s knowledge and perceptions may significantly influence parental attitudes and decision-making

Despite the increasing use of sedation in Pediatric Dentistry, misconceptions regarding its indications, safety, adverse effects and necessity may still exist among non-dental healthcare professionals. Limited awareness among pediatricians may contribute to delayed referrals, parental apprehension and reluctance toward essential dental treatment. Conversely, adequate understanding can enhance interdisciplinary collaboration, timely referral and improved oral health outcomes in children. However, literature assessing pediatricians’ knowledge, perception and awareness regarding sedation in Pediatric Dentistry remains limited, particularly in regional and developing healthcare settings.

In view of the important advisory role of pediatricians’ and the growing need for child-friendly dental care, it is essential to evaluate their understanding of sedation practices in pediatric dentistry. Therefore, the present questionnaire-based survey was undertaken to assess pediatrician’s knowledge, perception and awareness regarding sedation in Pediatric Dentistry.

METHODS

Study design

The present study employed a cross-sectional survey design to assess pediatrician’s knowledge, perception and awareness regarding sedation practices in Pediatric Dentistry. The study was conducted over a period of 3 months from January 2025 to March 2025. The study population included practicing pediatricians from hospitals, private clinics and healthcare institutions to ensure a diverse and representative sample.

Ethical clearance for the study was obtained from the Institutional Ethics Committee. Participation in the study was voluntary and informed consent was obtained digitally from all participants prior to inclusion in the study.

A structured questionnaire consisting of 16 multiple-choice questions was developed using Google Forms. The questionnaire was designed to assess three primary domains i.e. demographic details, knowledge regarding sedation practices in Pediatric Dentistry and perception and awareness related to these practices.

The questionnaire was distributed electronically through email and social media platforms such as WhatsApp and professional networks. Participants were assured of anonymity and confidentiality and only one response per participant was permitted. Periodic reminders were sent to improve the response rate.

Statistical analysis

A sample size of 123 participants was determined based on previous literature and standard statistical assumptions, with a confidence level of 95% and appropriate precision. A convenience sampling method was used for participant selection. Pediatricians who were willing to participate and provided complete responses were included in the study, whereas incomplete responses and duplicate entries were excluded.

The collected data were entered into Microsoft Excel and analyzed using Jamovi version 2.7.15. Descriptive statistics were used to summarize the demographic characteristics, awareness, perceptions, practices, barriers and training needs of the participants. Categorical variables were expressed as frequency and percentage.

Inferential statistics were performed using the Chi-square test to evaluate associations between categorical variables. Comparisons were carried out between demographic variables (experience and workplace) with knowledge- and practice-related parameters, knowledge variables with perception and practice variables, exposure-related variables with perception variables and barriers with perceived training needs. A p value of less than 0.05 was considered statistically significant.

RESULTS

A total of 123 pediatricians participated in the present study. The demographic characteristics of the participants revealed that the majority (74.8%) had less than 5 years of clinical experience, while 8.9% had 5-10 years of experience, 7.3% had 10-15 years of experience and 8.9% had more than 15 years of experience. Most participants were working in Government Hospitals/UHCs (58.5%), followed by other workplaces (22.0%), private clinics (11.4%) and multi-specialty hospitals (8.1%) as shown in Figure 1.

Awareness regarding pediatric dental sedation revealed that 85.4% of pediatricians were aware of the use of sedation in pediatric dentistry. Among the various sedation modalities, nitrous oxide sedation was the most recognized technique (74.0%), followed by oral sedation (59.3%) and general anesthesia (59.3%), whereas awareness regarding IV sedation was comparatively lower (22.8%) (Figure 2).

A majority of the participants (80.5%) were aware of the guidelines for pediatric dental sedation and 74.0% believed that pediatric dental sedation is safe when appropriately administered. However, 13.8% considered it unsafe and 12.2% were unsure regarding its safety. The primary indication for sedation in pediatric dentistry was selected as anxiety management by 43.9% of the participants, followed by pain control (30.9%), special health care needs (16.3%) and behavior management (8.9%) (Figure 3).

When assessing the role of pediatricians in pre-sedation evaluation, the majority (68.3%) believed that assessing the child’s physical fitness for sedation was their primary responsibility, other responses included providing clearance for sedation (16.3%), conducting thorough medical history review (7.3%) and no role in pre-sedation evaluation (8.1%). Medical history was considered the most important factor influencing consent for sedation by 68.3% of participants, followed by complexity of the dental procedure (13.8%), parental consent (9.8%) and child’s age (8.1%) as shown in Figure 4.

Most pediatricians (72.4%) reported that they occasionally encountered parents seeking advice regarding dental procedures requiring sedation, whereas 17.9% encountered such situations frequently. Safety risks were perceived as the primary parental concern regarding pediatric dental sedation by 69.9% of participants, while other concerns included cost of sedation (17.1%), lack of trained professionals (7.3%) and lack of awareness (5.7%) (Figure 5).

Cross-tabulation analysis between years of experience and study variables demonstrated statistically significant associations with awareness regarding pediatric dental sedation (p=0.001), nitrous oxide sedation (p<0.001), oral sedation (p<0.001), IV sedation (p=0.025) and general anesthesia (p<0.001). Pediatricians with less than 5 years of experience demonstrated comparatively greater awareness regarding use of sedation modalities. Significant associations were also observed between years of experience and awareness regarding sedation guidelines (p<0.001), perception regarding safety of sedation (p<0.001), understanding of the pediatrician’s role in pre-sedation evaluation (p<0.001), parental concerns regarding sedation (p<0.001) and perceived need for additional training and awareness programs (p<0.001) (Table 1). Overall, the findings of the present study highlighted that years of experience and workplace significantly influenced pediatricians’ awareness, perception and practices regarding pediatric dental sedation.

A statistically significant association was additionally observed between standardized sedation protocols and the perceived need for additional training and awareness programs (Chi-square=25.274, p<0.001). Participants who acknowledged the importance of standardized protocols demonstrated greater support for training programs (98.0%), while only 2.0% of participants showed limited support for additional training and awareness initiatives. However, no statistically significant association was observed between legal or regulatory challenges and the perceived need for additional training and awareness programs (Chi-square=1.178, p=0.278). These findings suggest that professional training deficiencies, infrastructural limitations and parental apprehension are major factors influencing the demand for enhanced education and awareness regarding pediatric dental sedation (Table 2).

DISCUSSION

The management of anxiety and uncooperative behaviour remains one of the greatest challenges in pediatric dentistry. Sedation has emerged as an important behaviour management technique that enables safe and effective dental treatment in anxious, fearful and medically compromised children. The present study evaluated pediatrician’s knowledge, perception and awareness regarding sedation in pediatric dentistry and highlighted important findings related to awareness of sedation techniques, safety perception, barriers and the need for additional training programs.

In the current study, 85.4% of pediatricians were aware of the use of sedation in pediatric dentistry. Nitrous oxide inhalation sedation was the most commonly recognized sedation modality (74.0%), followed by oral sedation and general anesthesia. These findings are similar to the study conducted by Chawla et al.¹³ who reported comparatively greater awareness regarding nitrous oxide inhalation sedation among dental practitioners in Gujarat due to its established safety profile and widespread clinical use. Similarly, Monisha et al observed that most dental practitioners possessed satisfactory awareness regarding conscious sedation techniques, although knowledge regarding advanced sedation modalities remained limited.¹⁴ Similar observations were also reported by Hamzah et al, who found that exposure to conscious sedation practices was comparatively higher for inhalational sedation than intravenous sedation among Malaysian dentists.¹⁵

The present study demonstrated that anxiety management was considered the primary indication for pediatric dental sedation by most participants. This finding is in accordance with the literature review by Aljohani et al, which emphasized that childhood dental anxiety and fear are major indications for conscious sedation in pediatric dentistry.¹⁶ Attri et al also reported that sedation plays a significant role in reducing anxiety, improving cooperation and facilitating safe completion of dental procedures in children.¹⁷ These findings indicate that pediatricians in the present study possess an appropriate understanding regarding the clinical indications for pediatric dental sedation.

A majority of pediatricians (74%) in the current study believed that pediatric dental sedation is safe when appropriately administered. This positive perception may be attributed to increased awareness regarding monitoring guidelines, emergency preparedness and patient selection criteria. Similar findings were reported by Riaño et al.¹⁸ who evaluated pediatrician’s opinions regarding sedation in children, where most participants considered sedation a valuable and safe behavior management technique when performed by trained professionals. However, concerns regarding complications and inadequate training were still reported in several studies, indicating the need for continued educational programs and structured clinical exposure.^16,17,19

The present study further demonstrated that parental fear or reluctance was perceived as the major barrier associated with pediatric dental sedation, followed by insufficient training for dental professionals and limited access to sedation facilities. Similar findings were reported in the Nepalese study by Shrestha et al, where lack of formal sedation training, inadequate emergency preparedness and limited facilities were identified as important barriers affecting sedation practice among pediatric dentists.¹⁹ Attri et al also reported that fear of adverse events and lack of adequate clinical exposure remain major concerns associated with pediatric dental sedation.¹⁷ These findings suggest that parental counseling and professional training programs are essential to improve acceptance and utilization of sedation techniques.

Another important finding of the present study was that the majority of pediatricians expressed the need for additional training and awareness programs regarding pediatric dental sedation. Similar findings were reported by Hamzah et al, who emphasized the importance of structured sedation training and continuing dental education programs for improving confidence and clinical exposure among practitioners.¹⁵ Shrestha et al also recommended regular emergency skill training and sedation courses to improve knowledge and practice regarding pediatric dental sedation.¹⁹

Overall, the present study suggests that pediatricians possess favorable awareness regarding pediatric dental sedation; however, gaps still exist regarding advanced sedation modalities and structured interdisciplinary training. Regular educational programs and collaboration between pediatricians and pediatric dentists may help improve awareness and safe sedation practice.

The present study had certain limitations. The study was conducted using a convenience sampling method and included a relatively limited sample size, which may affect the generalizability of the findings to the wider pediatrician population. As the study was questionnaire-based, responses were self-reported and therefore subject to response and recall bias. Furthermore, unequal distribution of participants among different workplace settings and years of experience may have influenced the study outcomes.

CONCLUSION

The findings of the present study indicate that pediatricians demonstrate satisfactory knowledge and positive perception regarding sedation in pediatric dentistry, particularly in relation to anxiety management and patient safety. Nitrous oxide sedation was the most commonly recognized sedation modality among the participants. Despite the overall favorable awareness, gaps were identified regarding advanced sedation techniques, professional training and accessibility of sedation facilities. Parental fear and reluctance were also perceived as major barriers to sedation acceptance. Most participants emphasized the need for additional training and awareness programs. Hence, continuous educational initiatives and improved collaboration between pediatricians and pediatric dentists are essential for promoting safe and effective pediatric dental sedation practices.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee (Approval No: (IECADC/154/2025)

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