The purpose of this review was to describe the potential influence of childhood obesity on pharmacosedation in pediatric dentistry and provide specific recommendations for managing obese patients. Increasingly common in the United States, childhood obesity poses specific challenges to the dentist. The greatest of these involve the increased potential for respiratory complications because of fat-induced restrictive lung disease and obstructive sleep apnea. Cardiovascular complications associated with obesity alone are rare in the pediatric patient, although hypertension is more likely. Gastrointestinal problems include increased likelihood for aspiration, necessitating strict fasting requirements. Sedative drugs dosed on total body weight may oversedate obese patients; dosages based on lean body mass may undersedate and usually produce a decreased duration of effect. Extra precautions regarding drug selection (such as avoiding opioids) and proper patient positioning can help minimize the incidence of complications.