UK National Clinical Guidelines in Paediatric Dentistry. Managing anxious children: the use of conscious sedation in paediatric dentistry

SONOPS Multicentre Cross-Sectional Study: Study of the Nitrous Oxide Perception and Use in French Dental Students

INTRODUCTION AND AIMS

EMONO (equimolar oxygen-nitrous oxide mixture) is widely used in dentistry to achieve sedation for dental care. In addition, pure nonmedical nitrous oxide (N2O) has become a very popular psychoactive substance among health students. Thus, for dental students, the perception of a same substance, N2O, which can either be used as medicine in the form of EMONO in their daily practice, or consumed illegally for recreational purposes in the form of pure nonmedical N2O, is of concern. This study aims to estimate the prevalence of N2O (EMONO and pure nonmedical N2O) use among French dental students.

METHODS

A cross-sectional multicentre study was carried out in six French dental schools. A self-administered questionnaire was offered to 2nd to 6th-year odontology students about their position with regard to N2O and its potential use.

RESULTS

The prevalence of N2O use among the 1124 responding students was 50.4%, with heterogeneity according to dental school. 84% of the students who used N2O did so at least once for recreational purpose, while 16% used it only in the context of care and/or training. Students with recreational N2O use were more likely to use other substances than students with care/training use. Nearly three-quarters of the students sought and experienced euphoria and laughter.

CONCLUSION

Nearly half the students in our study reported having used N2O recreationally, most of them regularly, a much higher prevalence than among nonhealthcare students.

CLINICAL RELEVANCE

The issue of the correct use of EMONO is particularly important at a time of increasing detour from medical to recreational use. As future healthcare professionals with easy access to this substance, dental students should be well versed in the use and abuse of nitrous oxide in dentistry.

Estimated compared with actual plans of paediatric dental treatment performed under deep sedation: A retrospective cohort study

BACKGROUND

Planning the extent of paediatric dental treatment under deep sedation is highly important, as the duration of the sedation should be limited to approximately 1 h, and the amount of local anesthesia is limited by the children's body weight.

AIM

To compare treatment plans estimated at initial examinations with actual dental treatments under intravenous deep sedation. We examined factors that could affect the differences.

DESIGN

For this retrospective cohort study, data were collected from the medical records of all the children younger than 18 years who underwent dental treatment under intravenous deep sedation during 2019-2021 at the Department of Pediatric Dentistry.

RESULTS

In total, 108 children were included. During the actual versus the estimated treatment under deep sedation, more teeth were treated (p < .001), and the treatment was more complex (p < .001). A longer waiting period for dental treatment was found to be correlated with a greater number of treated teeth than was estimated (p = .003) and with greater complexity of the actual than the estimated treatment (p = .003).

CONCLUSION

Actual compared with estimated dental treatment under deep sedation involved more teeth and was of greater complexity. This suggests that referrals should include children with limited estimated treatment plans.

Equimolar oxygen-nitrous oxide (EMONO) in dental pediatric care: which patients achieve therapeutic effects? A French national exploratory prospective observational multicenter study

PURPOSE

Equimolar oxygen-nitrous oxide mixture (EMONO) is considered as a reference for dental care in children. Completion of dental treatment has usually been used as a criterion to assess EMONO treatment. However, other patient-reported outcomes are needed. We sought to assess the prevalence of complete therapeutic effects (analgesia and anxiolysis) experienced by children during dental care under EMONO and identifying associated factors.

METHODS

A national prospective observational multicentric study was conducted between September 2018 and June 2020 in 13 French university hospitals. Participants were children between 3 and 15 years of age requiring dental care under EMONO.

RESULTS

677 children were analyzed. Anxiolysis and analgesia were experienced by a large majority of patients (86.5% and 79.0%, respectively, and 73% experienced both effects). Several factors were associated with both analgesia and anxiolysis effects: the presence of expected effects (no loss of judgment and slight decrease in level of consciousness), the absence of agitation and distress, a positive perception of EMONO and ethnicity.

CONCLUSION

Most patients benefit from the therapeutic effects (anxiolysis and analgesia) expected by EMONO during dental treatment. It is reassuring to observe that most sociodemographic characteristics and medical history do not seem to influence the effectiveness of care. The study was registered at www.

CLINICALTRIALS

gov under the reference number NCT03453411.

Case Study of a Broken Instrument in a Primary Tooth and Literature Review

BACKGROUND

Root canal treatment is an important element of dental treatment, and broken instruments are one cause of endodontic treatment failure. Broken instruments are rarely reported in primary teeth because of their inherently wider and relatively straighter root canals. We describe a case of a patient with a broken instrument in a primary tooth and reviewed the literature across three databases.

CASE PRESENTATION

A boy aged 7 years and 2 months was referred to our hospital because of pain persisting despite multiple dental treatments. Radiographic examination revealed a broken instrument in the maxillary right primary second molar. The patient experienced dental fear, so the treatment proceeded with the use of behavioral management and nitrous oxide, after which his pain disappeared. At the age of 9 years and 2 months, eruption of the successive permanent teeth was confirmed, and no pathological findings were observed except enamel hypoplasia. We undertook a literature review across three databases and found only two articles about broken instruments in primary teeth, neither of which described the eruption of the permanent teeth. All three cases involved primary molars.

CONCLUSIONS

We removed a broken instrument from the root of a primary molar and performed root canal treatment, resulting in a good outcome for the primary molar until it was replaced with successive permanent teeth. Although rare, broken instruments in the roots of primary molars do occur, and care should be taken during root canal treatment of primary molars.

The effect of dexmedetomidine-ketamine combination versus dexmedetomidine on behavior of uncooperative pediatric dental patients: a randomized controlled clinical trial

OBJECTIVE

Uncooperative behavior in pediatric dentistry is one of the most common manifestations of dental anxiety. Managing anxious patients can be attained by moderate sedation. This study aimed to compare the effect of sedation by dexmedetomidine-ketamine combination (DEX-KET) versus dexmedetomidine (DEX) on behavior of uncooperative pediatric dental patients.

METHODOLOGY

In total, 56 uncooperative healthy children (3-5 years old) requiring dental treatment were divided randomly into two groups: Group I (study group), which received buccal dexmedetomidine (2 μg/kg) and ketamine (2 mg/kg), and Group II (control group), which received only buccal dexmedetomidine (4 μg/kg). Drugs effects were assessed in terms of hemodynamic parameters, patient's drug acceptance, child behavior, postoperative effect of sedation, amnesic effect, incidence of adverse events, as well as procedural induced stress measured by salivary secretory immunoglobulin A (s-IgA).

RESULTS

Hemodynamic results did not reveal a statistically significant difference between the two study groups (P>0.05). There was a significant difference in patient's acceptance to sedative drug between both groups, favoring DEX (p=0.005). Children who received DEX-KET showed significantly better behavior than those who received DEX for local anesthesia (p=0.017) and during operative procedure (p=0.037). Adverse events, post-operative and amnesic effects of drugs were comparable in both groups (p>0.05). Moreover, the mean difference in the salivary s-IgA levels between initial and final value was not statistically significant between both groups (p=0.556).

CONCLUSION

Both DEX-KET combination and DEX alone are effective in providing hemodynamic stability. DEX-KET combination significantly improved the behavior of sedated children compared to DEX alone but the drug acceptance was decreased in the DEX-KET group. Both regimens did not have a negative effect on postoperative behavior of children and had comparable amnesic effect with no significant adverse events. Salivary s-IgA is not considered a potential stress biomarker in sedated children.

Modern sedative agents and techniques used in dentistry for patients with special needs: A review

According to the World Health Organisation, approximately 1.3 billion people worldwide experience substantial disability due to physical, mental or sensory impairment. People with special needs require special consideration and more time or altered delivery methods when receiving dental treatments. Various factors, such as patients' lack of cooperation, cognitive impairment and complex medical status, may lead dental practitioners to recommend conscious sedation. Several pharmacological agents and administrative routes are available, which achieve varying levels of sedation ranging from minimal to deep. Pre-operative assessment and careful case selection are necessary to determine the appropriate sedative agent, route of administration and level of sedation for each patient. Thus, a thorough understanding of the pharmacokinetics, risks and benefits, and implications of various sedatives available for PSN is essential to achieve the desired clinical outcomes. This review critically presents the considerations associated with the use of various sedative agents for PSN in dentistry. Considerations include patients' pre-anaesthesia medical comorbidities, cardiorespiratory adverse effects and cooperativeness, and the viable alternative treatment modalities.

Barriers to Using Advanced and Pharmacological Behavior Management Techniques: A Survey of Pediatric Dentists in Jeddah, Saudi Arabia

Aim

In this study, we assessed the use of advanced pharmacological behavior management techniques (BMTs) among pediatric dentists in Saudi Arabia and the barriers to their clinical application.

Materials and Methods

This cross-sectional study used a self-administered electronic survey that targeted members of the Saudi Society of Pediatric Dentistry. The questionnaire included questions on five techniques of advanced and pharmacological behavior management recommended by the American Academy of Pediatric Dentistry. Descriptive statistics, frequency, Chi-square test, and Fisher's exact test were used to present the outcomes and independent variables.

Results

A total of 57 pediatric dentists completed the survey. Nitrous oxide (N2O) sedation, general anesthesia (GA), and protective stabilization were used regularly by pediatric dentists in 70.2%, 68.4%, and 56.1% of the participants, respectively. A few participants reported using oral (14.0%) or intravenous (IV) sedation (10.5%) regularly. The most common barriers to using these techniques were either dentists' discomfort or the non-availability of the equipment/drugs.

Conclusions

The most common method used by pediatric dentists was N2O inhalation sedation, followed by GA and protective stabilization. The participants' use of pharmacological BMTs, including IV and oral sedation, was relatively low.

Ketamine-propofol (ketofol) in procedural sedation: a narrative review

Sedation methods for dental treatment are increasingly explored. Recently, ketofol, which is a combination of ketamine and propofol, has been increasingly used because the advantages and disadvantages of propofol and ketamine complement each other and increase their effectiveness. In this review, we discuss the pharmacology of ketamine and propofol, use of ketofol in various clinical situations, and differences in efficacy between ketofol and other sedatives.

Procedural sedation in pediatric dentistry: a narrative review

Procedural sedation and analgesia are now considered standard care for managing pain and anxiety in pediatric dental patients undergoing diagnostic and therapeutic procedures outside of the operating room. Anxiolysis, which combines both pharmacologic and non-pharmacologic approaches, plays a significant role in procedural sedation. Non-pharmacologic interventions such as Behavior Management Technology can help reduce preprocedural agitation, ease the transition to sedation, reduce the required amount of medication for effective sedation, and decrease the occurrence of adverse events. As the introduction of novel sedative regimen and methods in pediatric dentistry, the potential role of mainstay sedatives administered by new routes, for new indications, and with new delivery techniques, should be considered. The purpose of this paper is to examine and discuss the current state of sedation techniques in pediatric dentistry.

The Effect of General Anesthesia on the Outcome of Root Canal Treatment in Pediatric Patients—A Retrospective Cohort Study

This study aimed to evaluate the effect of general anesthesia (GA) on the 1-year outcome of Root Canal Treatment (RCT) performed in pediatric patients and to compare it to the outcome of RCT in pediatric patients without GA. Patients admitted for RCT in permanent dentition in a public hospital, dated 2015 to 2020, age 8–15 with a minimum of one year follow-up period, were included in the study. The sample consisted of 326 teeth from 269 patients treated by a single operator, with a recall rate of 81%. Overall, 124 teeth were treated under GA and 142 teeth were without GA. The mean follow-up time was 31.5 months. Data underwent statistical analysis and the significance threshold was set for p < 0.05. Of the total cases, 90% showed favorable outcomes. A significantly higher favorable outcome was seen in the GA group than in the non-GA group (98% and 85%, respectively, p < 0.001). The outcome was significantly affected by the type and quality of the coronal restoration, degree of root development, and lesion size (p < 0.05). According to the current study, in uncooperative pediatric patients, a more favorable outcome of root canal treatment can be obtained under GA than LA if the procedure is carried out with immediate restoration.

Nociception associated with pain/distress in young children sedated for dental treatment: a clinical study with objective and subjective measures

PURPOSE

To evaluate the association between children's pain/distress levels and patient characteristics (age, sex, history of dental pain), sedation type (level of sedation, sedative regimen), nociception and pain intensity reported by the parents in sedated children undergoing minimally invasive dental treatment.

METHODS

This clinical study evaluated secondary outcomes of an RCT that evaluated the efficacy of dexmedetomidine sedation with or without ketamine. Only children who had nociception levels recorded using the Analgesia Nociception Index (ANI) were included (0-100; 0 = highest nociception). FLACC scale (Face, Legs, Activity, Cry and Consolability) was used to assess children's pain/distress (0-10; 0 = no pain/distress). Parental proxy report of the child's pain intensity during the treatment was performed using the Visual Analogue Scale (VAS; 0-100; 0 = no pain). The association between ANI, children's age and sex, dental pain history, sedation level, sedative regimen, and VAS with the FLACC was verified using the generalised estimation equation analysis (alpha 0.05).

RESULTS

Participants were 31 children (51.6% boys) and their parents (90.3% mothers). Median FLACC was 3.3 (25th-75th percentiles 1.7-8.2), ANI 80.9 (74.7-85.8), and VAS 10 (1-23). FLACC associated with ANI (OR 0.96; 95% CI 0.93-0.99; p = 0.02), moderate sedation (0.13; 0.03-0.50; p = 0.003), and VAS (1.05; 1.01-1.10; p = 0.01).

CONCLUSION

Pain/distress was generally low and more prominent with minimal (versus moderate) sedation and higher nociception.

Conscious Sedation for Dental Treatments in Subjects with Intellectual Disability: A Systematic Review and Meta-Analysis

This systematic review and meta-analysis was aimed to investigate the conscious sedation efficiency in patients with intellectual disability undergoing dental treatment (PROSPERO CRD42022344292). Four scientific databases were searched by ad-hoc prepared strings. The literature search yielded 731 papers: 426 were selected, 42 were obtained in full-text format, and 4 more were added after hand searching. Fourteen studies were finally included, 11 of which were included in the meta-analysis (random effect model). A high heterogeneity in the drugs used and route of administration was retrieved. Success rate, occurrence of side effects, and deep sedation occurrence were combined to give an overall efficiency of each drug. N2O/O2 reported the highest efficiency (effect size = 0.90; p < 0.01) and proved to be more efficient when used alone. Nine papers reported a success rate of sedation of 80% or more. The prevalence of side effects (6 studies) ranged from 3% to 40%. Enteral and parenteral benzodiazepines showed the same overall efficiency (effect size = 0.86). No meta-analysis has yet been conducted to define the most effective and safest way to achieve conscious sedation in patients with intellectual disability; nitrous oxide appears to be the best choice to perform conscious sedation in patients with intellectual disability undergoing dental treatment.

Management of Post-Traumatic Dental Care Anxiety in Pediatric Dental Practice-A Clinical Study

BACKGROUND

It is important to avoid giving children traumatic dental experiences that induce post-traumatic dental care anxiety (PTDA) in clinical dental practices. The aim of this study was to evaluate whether non-pharmacological behavior management procedures can effectively reduce the use of pharmacological behavior management in children who have PTDA and are referred for regular dental treatments under general anesthesia (GA) and sedation.

METHODS

This clinical study consisted of two groups. The treatment group involved 20 healthy children aged 4-14 with PTDA and also those referred by other institutions for dental treatment with/without GA. The control group was sampled retrospectively from the patient records and involved 20 healthy uncooperative children aged 4-14 with PTDA who had been treated under GA.

RESULTS

The number of multiple appointments was significantly higher in the treatment group than in the control group. Only 25% of children in the treatment group underwent GA and the rest (75%) were managed with non-pharmacological management techniques. Nine (60%) children who were treated with minimally invasive techniques did not require GA.

CONCLUSIONS

It is important to treat children as much as possible without causing PTDA by using appropriate behavior management techniques. This study emphasizes the usefulness of thoroughly employing non-pharmacological behavior management methods before directing a child with PTDA for dental treatment under pharmacological behavior management, which can prevent the over-utilization of sedation and GA.

Use of pulse oximetry during nitrous oxide- oxygen inhalation sedation: mandatory or recommended?

AIM

There is skepticism amongst many dentists about the interference of nitrous oxide with the physiological parameters. This commentary attempts to make clear recommendations on the use of pulse oximeter during nitrous oxide inhalation sedation.

BACKGROUND

Nitrous oxide is used commonly in dentistry as a tool to reduce fear/ anxiety and build a positive dental attitude. Dentists use pulse oximeter to monitor oxygen saturation during the period of administration of nitrous oxide. There is no consensus amongst various guidelines across the world on the necessity of using pulse oximeter during the period of administration of nitrous oxide CONCLUSION: Pulse oximetry may not be considered mandatory when nitrous oxide gas is being administered for minimal sedation to a healthy patient having no pre- existing diseases/illness.

Effect of immersive virtual reality on pain in different dental procedures in children: A pilot study

BACKGROUND

Implementing effective pain management is important to increase patient compliance during paediatric dental procedures.

AIM

This pilot study was conducted to evaluate the effectiveness of virtual reality (VR) on pain perception in dental procedures in children.

MATERIAL AND METHODS

Fifty-four children aged between 5 and 12 years were included. Patients scheduled to receive dental procedures not requiring local anesthesia (eg, fluoride therapy) were assigned to Group A, and patients scheduled to receive painful dental procedures requiring local anesthesia (eg, pulp therapy, teeth extraction) were assigned to Group B. Patients in each group were randomly assigned and were equally likely to either receive VR during their dental procedure, or treatment as usual (without VR). Visual analog scale (VAS), Wong-Baker FACES rating scale, and the 'Face, Legs, Activity, Cry, Consolability' scale (FLACC scale) were used to assess the pain levels during dental procedures.

RESULTS

Patients receiving painful dental procedures requiring local anesthesia reported significant reductions in pain intensity/worst pain during the dental procedure on all subjective and behavioral pain measures of pain intensity with the use of VR distraction technique (P < .05 on each). Patients receiving non-painful dental procedures showed the predicted pattern but no significant reduction in worst pain during VR.

CONCLUSION

The use of VR was found to be an effective distraction tool to ease pain and anxiety in the tested dental procedures, for children receiving painful dental procedures.

Intranasal versus sublingual route of dexmedetomidine sedation in paediatric dentistry: A randomized controlled clinical trial

BACKGROUND

Many children experience dental anxiety during dental treatment. Conscious sedation is used to alleviate anxiety and enhance a child's cooperation.

AIM

This study aimed to compare the efficacy of intranasal versus sublingual dexmedetomidine.

DESIGN

Forty-two healthy, uncooperative children participated in the study. They were divided randomly into two groups: In the first visit, Group I received intranasal dexmedetomidine and group II received sublingual dexmedetomidine, whereas at the second visit, the alternate route was implemented in a crossover design. The child's acceptance of drug administration method was assessed using a 4-point rating scale. Time until optimum sedation was measured. Anxiety during local anesthesia administration was scored using Venham's rating scale. Postoperative response was recorded through Vernon et al's questionnaire.

RESULTS

The sublingual dexmedetomidine route was better accepted than the intranasal route (P=0.01), while the latter acted faster (P>0.001). No significant difference in anxiety scores was found between groups at baseline (P=0.84) or during local anesthetic administration (P=0.44). No negative effect was recorded by the parents who answered the Modified Vernon et al questionnaire 24 hour after the dental visit compared to before the dental visit (P=1.00).

CONCLUSIONS

Both routes prevented the increase in anxiety scores equally during local anesthesia and do not have negative effect on postoperative behavior of children. However, the sublingual route showed better acceptance with longer onset time of action than the intranasal route.

Effectiveness of biofeedback relaxation and audio-visual distraction on dental anxiety among 7- to 12-year-old children while administering local anaesthesia: A randomized clinical trial

BACKGROUND

Local anaesthesia (LA) administration provokes dental anxiety in children. BrightHearts is a biofeedback relaxation application designed to reduce anxiety in children during painful procedural interventions.

AIM

To compare the effectiveness of biofeedback relaxation (BR) and audio-visual (AV) distraction on dental anxiety among 7- to 12-year-old children while administering LA.

DESIGN

A total of 70 children requiring dental treatment under LA for three visits were recruited for this single-blinded randomized control trial. They were randomly divided into two equal groups. Group A received BR and Group B received AV distraction during LA delivery in the first two visits, and both groups did not receive any intervention during LA in third visit. Outcomes were measured using heart rate and a cartoon-based anxiety measuring scale (Chotta Bheem-Chutki (CBC) scale).

RESULTS

AV group had statistically significant higher mean heart rates than BR group (P < .001) during needle penetration and post-intervention, respectively. CBC scale showed no statistical differences between the groups.

CONCLUSION

Both the interventions are effective in reducing dental anxiety during LA administration. Based on objective measures, BR is found to be better than AV distraction. Subjective scores, however, show no differences between the two.

Is aromatherapy associated with patient's dental anxiety levels? A systematic review and meta-analysis

The use of aromatherapy for the reduction of anxiety levels during dental treatment procedures has been well established in the literature; however, there is limited evidence regarding its efficacy. The present meta-analysis is an attempt to assess the association between the use of aromatherapy and anxiety levels among dental patients. A comprehensive search was conducted across Medline, Scopus, Web of Science, EBSCO host, Cochrane databases, and Google Scholar for studies evaluating aromatherapy and anxiety level among dental patients. PRISMA guidelines were followed for the meta-analysis. Randomized and cluster-randomized trials comparing aromatherapy with controls were included. The random-effects model was used to assess the mean differences in anxiety levels of patients visiting dental OPD. The significance value was set at P < 0.05. Six studies were identified that met the requirements for inclusion. Aromatherapy was significantly associated with reduction in patient anxiety levels during dental treatment (pooled mean difference: −3.36 [95% CI, −3.77 – −2.95, P = 0.00001). Low heterogeneity was noted between studies (I² = 1%, P = 0.41) analyzed in the meta-analysis. High certainty of the evidence was obtained from the association between the use of aromatherapy and dental anxiety. This meta-analysis suggests that aromatherapy is effective in reducing dental anxiety. When used judiciously, the results of this work should encourage the use of aromatherapy to reduce patient anxiety levels during dental procedures

Dentist-administered cognitive behavioural therapy versus four habits/midazolam: An RCT study of dental anxiety treatment in primary dental care

The study aimed to test the effectiveness of cognitive behavioural therapy (CBT) administered by a general dental practitioner (GDP) in a general dental practice. In a two-arm parallel randomised controlled trial, the experimental group received a short dentist-administered CBT-intervention (D-CBT). A best-practice control group (FHM) received dental treatment during sedation with midazolam combined with an evidence-based communication model (The Four Habits Model). Ninety-six patients with self-reported dental anxiety were allocated to the treatment arms at a 1:1 ratio. Modified Dental Anxiety Scale (MDAS) scores spanned from 12 to 25, and 82 patients (85%) had a score of 19 or more, indicating severe dental anxiety. In both treatment arms, scores on MDAS and Index of Dental Anxiety and Fear (IDAF-4C) decreased significantly, but no differences were found between treatment arms. Mean reductions were: MDAS scores: -6.6 (SD = 0.5); IDAF-4C scores: -1.0 (SD = 1.1). In conclusion, local GDPs in general dental practices with proper competence have the ability for early detection of dental anxiety and, with the use of a manual-based D-CBT or FHM treatment, GDPs could offer efficient first-line treatment suitable for dental anxiety of varying severities.

Pediatric dental treatments with pharmacological and non-pharmacological interventions: a cross-sectional study

Objectives

Behaviour management strategies involving pharmacological or non-pharmacological interventions during dental procedures should be considered to attain safe and successful treatment outcomes. This study compared the frequencies of use and the completeness of treatment with these interventions.

Methods

A total of 1725 dental records of patients up to 18 years old, who were treated in the King Abdulaziz Medical City in Jeddah City from October 2018 to June 2019, were used in this retrospective, cross-sectional study. Inferential analysis, Chi-square test, Kruskal–Wallis test, and regression model were used in the data analysis.

Results

About two-thirds of the patients were treated with attendant non-pharmacological interventions, while one-third, with pharmacological interventions. The application of General Anesthesia (GA) was the most frequently used intervention. Restorative procedures and extractions were done in higher frequencies with pharmacological interventions. Treatments with space maintainers and orthodontic appliances were carried out in higher frequencies with non-pharmacological strategies. The choice of intervention was significantly influenced by the systemic conditions of the patients. Patients treated with non-pharmacological intervention comprised the dominant type of patients, because they required treatments with less pain. Those treated with GA needed restorative treatments and extractions, or treatments that involve pain, but these treatments had higher frequencies of being completed.

Conclusions

The treatments with pharmacological intervention through GA have higher frequencies of being completed, compared to those with non-pharmacological interventions. Factors, such as age, potential to complete the treatment, and the type of dental treatment applied, influence the choice of treatment intervention.

Sedative and Behavioral Effects of Intranasal Midazolam in Comparison with Other Administrative Routes in Children Undergoing Dental Treatment - A Systematic Review

AIM

The aim of this study was to systematically identify and evaluate the available literature on the effectiveness of intranasal midazolam sedation compared with midazolam administered through other routes in the sedation and behavior management of children during dental treatment.

MATERIALS AND METHODS

The search was done using electronic databases such as PubMed Central, Cochrane Database of Systematic Reviews, LILACS, ScienceDirect, and SIGLE. All studies comparing the sedative effect and behavior management effectiveness of intranasal midazolam with midazolam administered through other routes in children were included.

RESULTS

Electronic database search identified 163 articles, out of which 143 were excluded after reading titles and removing duplication. The remaining 20 studies were evaluated in detail. A final of 13 studies were included based on the inclusion criteria. Among the 13 studies included in the present review, a high risk of bias was noted in all the 13 articles. There was no adequate blinding of personnel and participants in the study, allocation concealment was improper and presence of inadequate blinding of the outcome assessment. . Statistically, no significant difference was observed between intranasal midazolam and other midazolam routes on behavior and sedation level in the studies included in this review.

CONCLUSION

Limited studies are available pertaining to the sedative and behavioral effects of intranasal midazolam, and thus, this review recommends need for more research evaluating the sedative effect of intranasal midazolam in comparison with midazolam administered through other routes in the behavior management of children during dental treatment.

Sedation or General Anaesthetic for Special Care Patients?

When faced with an anxious patient with complex needs who requires dental care, it can be difficult to decide on the most appropriate method to manage their pain and anxiety. There are a range of conscious sedation techniques that may be used, and on some occasions, general anaesthesia may be required. This paper describes the methods available and the factors influencing the decision-making process. The general dental practitioner (GDP) may not be able to offer care in their setting, but knowing more about the decision-making process and the information required to make that decision can help them guide patients and their families.

Midazolam use in pediatric dentistry: a review

Behaviour management and dental procedures performed in very young, pre-cooperative, highly anxious, or medically disabled children are challenging tasks. Various drugs and methods have, however, been introduced to facilitate treatment for this patient population. Midazolam is a benzodiazepine used as an adjunct to behavior management techniques in the dental treatment of pediatric patients. Midazolam can be used as a safe and effective drug for conscious sedation, general anesthetic premedication, and treatment of seizures during dental procedures. Nevertheless, further research involving pediatric patients would be beneficial.

Effect of Virtual Reality Distraction on Pain and Anxiety During Dental Treatment in 5 to 8 Year Old Children

OBJECTIVE

This study was aimed at assessing the impact of Virtual Reality (VR) distraction technique on pain and anxiety in 5-8-year-old children, during short invasive dental procedures.

STUDY DESIGN

120 children, aged 5-8 years, scoring less than 25 on the SCARED questionnaire, scheduled to undergo short invasive dental procedures, were randomly divided into a control (without VR distraction) and study group (with VR distraction) of 60 each. State anxiety levels were assessed in the children from both groups using revised version of Modified Child Dental Anxiety Scale, before and after dental treatment. Pain perceived during treatment was assessed using Wong Baker Faces pain rating scale at the end of treatment. Salivary cortisol levels were also assessed before, during and after the dental procedure, in all children.

RESULTS

We observed a significant reduction in pain perception and state anxiety in children, using VR distraction (p<0.001, p=0.002). The decrease in salivary cortisol levels was significantly greater in children using VR distraction (p<0.001).

CONCLUSION

Virtual Reality distraction can be used as a successful behavior modification method in children undergoing short invasive dental treatments.

Safety and effectiveness of intramuscular ketamine sedation in the management of children with oro-dental trauma in a paediatric emergency department

BACKGROUND/AIMS

Ketamine sedation has not been reported to be widely used as a pharmacological behavioural management strategy to facilitate the treatment of acute paediatric oro-dental trauma. The aim of this study was to investigate the safety and effectiveness of intramuscular ketamine sedation for managing paediatric oro-dental trauma in a paediatric Emergency Department (ED).

METHODS

The database of all paediatric procedural sedations performed in the hospital ED from 01 January 2014 to 31 December 2016 was reviewed to identify cases where intramuscular ketamine sedation was administered for dentists' treatment of oro-dental trauma. Patient demographics and epidemiological data, the type and number of sedation-related adverse events, and interventions performed were extracted from the database. Clinical notes were reviewed to verify the dental diagnoses and dental treatment performed. Adverse events were further risk stratified using the World SIVA adverse event reporting tool.

RESULTS

In the study period, 167 intramuscular ketamine sedations were administered by ED doctors for dental treatment of oro-dental trauma. The patients' median age was 3.6 years (range 1.1 to 12 years). All dental procedures were successfully completed. Nineteen adverse events were reported (11.4%, n = 19) with the most common being emesis (9.0%) followed by transient desaturation (1.8%) and hypersalivation (0.6%). The lowest oxygen saturation level was 90%. None of the patients aspirated, and none required assisted ventilation or chest compression. The most common dental diagnosis was primary tooth luxation (49.1%). The most common dental treatment was primary teeth extraction (70.7%). When adverse events were stratified using the World SIVA tool, there were only 17 (10.2%) minor risk outcomes.

CONCLUSIONS

The data support the safety and effectiveness of intramuscular ketamine sedation administered by trained ED doctors to facilitate the management of paediatric oro-dental trauma emergencies.

Should Melatonin Be Used as an Alternative Sedative and Anxiolytic Agent in Mandibular Third Molar Surgery?

PURPOSE

Melatonin is a natural hormone that regulates circadian rhythms. The aim of this study was to compare the anxiolytic effects of oral melatonin and oral midazolam in patients undergoing third molar surgery. The study also sought to investigate the effects of these drugs on cognitive and psychomotor functions.

MATERIALS AND METHODS

This was a double-blinded, prospective, randomized clinical study. Patients scheduled for impacted third molar surgery were included in the study. Anxiety was evaluated with the visual analog scale (VAS). To measure psychomotor and cognitive functions before the procedure, all patients were asked to complete the digit symbol substitution test (DSST) and the trail making test (TMT parts A and B). Then, all patients were allocated to 1 of 3 groups to receive oral midazolam 0.2 mg/kg (group MD), oral melatonin 0.4 mg/kg (group M), or an oral multivitamin tablet as placebo (group P). After 60 minutes, patients were reassessed using the same 3 tests. The difference between the pre- and post-drug VAS values was calculated and the anxiolytic effects of the drugs were evaluated.

RESULTS

Ninety patients participated in the study. No relevant differences were observed among groups for age, gender, or duration of operation. The results suggested that anxiety decreased most in group MD (P < .001), but anxiety in group M also decreased significantly compared with group P (P = .016). Similarly, the greatest increase in TMT-A and -B score differences was in group MD compared with the other groups (P < .001), whereas there was no significant difference between groups M and P for TMT-A and -B scores (P = .913 and P = .964, respectively).

CONCLUSION

Melatonin showed sufficient anxiolytic effect in third molar surgery without affecting cognitive and psychomotor functions.

Determination of the maximum tolerated dose of intranasal sufentanil and midazolam in Chinese: a pilot study

BACKGROUND

The purpose of this study was to determine the maximum tolerated dose (MTD, the dose of causing 10% respiratory depression) of intranasal sufentanil (SUF) and midazolam (MID) for sedation during gastroscopy by continual reassessment method (CRM).

METHODS

Patients (18-65 years old) scheduled for gastroscopy were recruited in this study. Subjects received intranasal SUF and MID for sedation. The dose of MID (5 mg) was fixed, while the dose of SUF was increased progressively (six incremental doses ranging from 0-0.60 μg/kg, n = 3 for each dose). The first cohort received a conservative, predetermined dose of 5 mg MID and 0 μg/kg SUF, subsequent cohorts received doses of SUF that were determined by the responses of all previous patients using Bayesian-based software. The dose allocated to the next cohort is the one with an updated posterior response probability closest to 10%.

RESULTS

Thirty Chinese patients scheduled for gastroscopy were included. Probability of respiratory depression at each dose was as follows: 5 mg MID + 0 μg/kg SUF, 0.4%; 5 mg MID + 0.1 μg/kg SUF, 0.8%; 5 mg MID + 0.2 μg/kg SUF, 1.8%; 5 mg MID + 0.3 μg/kg SUF, 3.7%; 5 mg MID + 0.4 μg/kg SUF, 9.9%; 5 mg MID + 0.5 μg/kg SUF, 17.8%; 5 mg MID + 0.6 μg/kg SUF, 36.0%.

CONCLUSION

The MTD of intranasal MID and SUF for sedation during gastroscopy causing 10% respiratory depression is 5 mg MID + 0.4 μg/kg SUF, based on CRM.

Nitrous Oxide and Midazolam Sedation: A Systematic Review and Meta-Analysis

Nitrous oxide and midazolam have been used as sedative agents to decrease fear and anxiety associated with dental procedures. Although these agents have been widely used individually, the combination of the two is also commonly used. Four clinical trials were identified that compared the combination technique with the individual use of the drugs. The standardized mean difference (SMD) for each outcome measure was considered for final analysis. Three studies with 534 participants were included in the final meta-analysis, and the SMD [95% CI] was obtained as -0.15 [-0.32, 0.03] and was not statistically significant for cooperation scores. Two studies reported the dose of midazolam required for inducing sedation in 450 participants, and the pooled estimate of SMD [95% CI] was obtained as -0.29 [-0.48, -0.10] and was significant. Two studies with 450 participants reported the time taken to recover from sedation, and the pooled estimate of SMD [95% CI] was obtained as -0.20 [-0.39, -0.01] and favored the combination technique. To conclude, the combination technique combines the pros and cons of both drugs in causing fewer adverse effects due to midazolam by reducing the total dose and also helps to provide better acceptance of nitrous oxide inhalation.

Treatment outcomes of using inhalation sedation for comprehensive dental care

Aim

To assess the outcomes of dental treatment under inhalation sedation within a UK specialist hospital setting.

Methods

This was a retrospective cohort study of the case notes of patients under 17 years of age who received dental treatment using inhalation sedation at a UK specialist setting during the period 2006–2011. Treatment outcomes were categorised into five groups: (1) treatment completed as planned, (2) modified treatment completed, (3) treatment abandoned in sedation unit and patient referred for treatment under general analgesia (GA), (4) treatment abandoned in sedation unit and patient referred for treatment under local analgesia (LA), (5) child failed to return to complete treatment.

Results

In total, the case notes of 453 patients were evaluated. The mean age of the patients was 10.3 ± 2.9 years. Treatment was completed successfully in 63.6% of the cases, 15.9% were referred for treatment under GA, 11.2% failed to return to complete the treatment, 7.1% received modified treatment completed, and only 2.2% were referred for treatment under LA. Treatment outcomes were significantly associated with patient`s age (p = 0.002). The treatment outcome “treatment abandoned and child referred to be treated under GA” had significantly lower mean patient ages than the other outcomes.

Conclusions

The majority of children referred for inhalation sedation, completed their course of treatment. A significantly higher proportion of those in the younger age group required GA to complete their treatment.

Survey of the sevoflurane sedation status in one provincial dental clinic center for the disabled

Background

Sevoflurane sedation in pediatric and disabled patients has the advantage of faster induction and recovery compared to general anesthesia, as well as minimum influence on the respiratory and cardiovascular functions, and airway protective reflexes. This study aimed to evaluate the clinical efficacy of sevoflurane sedation used in dental treatment at one provincial dental clinic center for the disabled.

Methods

We investigated patients' gender, age, reasons for undergoing sedation, medication history prior to treatment, duration of anesthesia, treatment length, type of treatment, and yearly patterns, for 387 cases of dental treatment performed using sevoflurane sedation from January 2013 to October 2016.

Results

We analyzed 387 cases (215 male patients, 172 female patients). Male patients aged 20 year or older accounted for 39.0% of all patients, marking the highest proportion. Patient's lack of cooperation was the most common reason for performing dental sedation. Prosthetic treatment was the most frequently practiced, accounting for 174 treatment cases. The mean lengths of the entire treatment and of the dental procedure were 55.2 min and 39.8 min, respectively.

Conclusions

Sevoflurane sedation has the advantage of fast anesthesia induction and recovery compared to general anesthesia; therefore, it can be used efficiently to induce anesthesia in pediatric and disabled patients during short dental procedures, enabling stable treatment of these patients.

Can intravenous conscious sedation with midazolam be effective at facilitating surgical dentistry in adolescent orthodontic patients? A service evaluation

Background Surgical dentistry during orthodontic care often occurs in adolescence and may involve surgical removal or exposure of teeth. The invasive nature of treatment, combined with dental anxiety, means care can often be provided under general anaesthesia (GA). Best-practice guidelines however endorse conscious sedation as an alternative, where appropriate. Although a limited number of studies have shown safe and effective use of intravenous conscious sedation (IVCS) with midazolam in this cohort, robust evidence to support routine use is lacking. Aim To assess whether IVCS with midazolam can effectively facilitate surgical dentistry in adolescent orthodontic patients in primary care.Method A retrospective service evaluation was undertaken reviewing clinical records of adolescents (aged 12-15 years) undergoing surgical exposure and/or surgical removal of teeth under IVCS with midazolam.Results A total of 174 adolescents (mean age 14.2 years) attended for treatment between 2009 and 2015. Of these adolescents, 98.9% (N = 172) allowed cannulation, with all surgical dentistry completed during a single visit. Midazolam dose ranged from 2-7 mg with 79.1% of patients having good or excellent cooperation and three minor adverse events occurring.Conclusion This service evaluation shows IVCS with midazolam can effectively facilitate surgical orthodontics in carefully selected adolescents. There is however a distinct need to further explore potential for this technique to provide a viable alternative to GA.

Inhalation Conscious Sedation with Nitrous Oxide and Oxygen as Alternative to General Anesthesia in Precooperative, Fearful, and Disabled Pediatric Dental Patients: A Large Survey on 688 Working Sessions

Aim. To evaluate the effectiveness and the tolerability of the nitrous oxide sedation for dental treatment on a large pediatric sample constituting precooperative, fearful, and disabled patients. Methods. 472 noncooperating patients (aged 4 to 17) were treated under conscious sedation. The following data were calculated: average age; gender distribution; success/failure; adverse effects; number of treatments; kind of dental procedure undertaken; number of dental procedures for each working session; number of working sessions for each patient; differences between males and females and between healthy and disabled patients in relation to success; success in relation to age; and level of cooperation using Venham score. Results. 688 conscious sedations were carried out. The success was 86.3%. Adverse effects occurred in 2.5%. 1317 dental procedures were performed. In relation to the success, there was a statistically significant difference between healthy and disabled patients. Sex and age were not significant factors for the success. Venham score was higher at the first contact with the dentist than during the treatment. Conclusions. Inhalation conscious sedation represented an effective and safe method to obtain cooperation, even in very young patients, and it could reduce the number of pediatric patients referred to hospitals for general anesthesia.

Utilising a paediatric version of the indicator of sedation need for children's dental care: a pilot study

AIM

To assess the treatment outcomes of using inhalation sedation for comprehensive dental care in children by utilising a modified version of the indicator of sedation need tool.

METHODS

Investigating the outcomes of dental treatment of patients referred to the sedation unit at the Leeds Dental Institute when the paediatric version of the indicator of sedation need (p-IOSN) was utilised.

RESULTS

Forty patients of mean age 9.99 (SD = 3.14) years were followed up to ascertain treatment outcomes when the p-IOSN was used. Of the total of 40 children included, 20 scored 6 on p-IOSN. Treatment completion rate was 72.5 %. Although major differences existed between age and treatment outcomes, they failed to achieve statistical significance. No significant association was found between gender and p-IOSN of any score with any treatment outcome.

CONCLUSIONS

p-IOSN may be a useful tool that can be used to predict those child patients who would benefit from sedation for their dental treatment. However, the p-IOSN is still in a developmental stage and further research is required prior to its use on clinical grounds.

Techniques to administer oral, inhalational, and IV sedation in dentistry

BACKGROUND

Sedation in dentistry is a controversial topic given the variety of opinions regarding its safe practice.

AIMS

This article evaluates the various techniques used to administer sedation in dentistry and specific methods practiced to form a recommendation for clinicians.

METHODS

An extensive literature search was performed using PubMed, Medline, Google Scholar, Google, and local library resources.

RESULTS

Most of the literature revealed a consensus that light sedation on low-risk American Society of Anesthesiologists (ASA) groups, that is ASA I, and possibly II, is the safest method for sedation in a dental outpatient setting.

CONCLUSION

Formal training is essential to achieve the safe practice of sedation in dentistry or medicine. The appropriate setting for sedation should be determined as there is an increased risk outside the hospital setting. Patients should be adequately assessed and medication titrated appropriately, based on individual requirements.

Dentists' and Parents' Attitude Toward Nitrous Oxide Use in Kuwait

The aim of this study was to investigate the attitude of dentists in Kuwait toward the use of nitrous oxide sedation as a behavior management technique (BMT) for pediatric patients and assess their training in nitrous oxide sedation. In addition, we assessed parents' knowledge of and attitude toward the use of nitrous oxide as a BMT for their children. The objective was to determine if nitrous oxide sedation is being provided and utilized as a means to enhance dental care for pediatric patients. A cross-sectional survey was randomly distributed to both groups of interest: parents accompanying their children to the dentist and licensed dentists in Kuwait. Participants had to meet certain inclusion criteria to be included in the survey and had to complete the entire questionnaire to be part of the analysis. A total of 381 parents completed the questionnaires. The majority of parents responded that they were unaware of nitrous oxide sedation and were not aware of it as a BMT (79%). Two thirds of the parent would accept nitrous oxide sedation if recommended by a dentist treating their children. Two hundred and one dentists completed the survey and met the inclusion criteria. The majority (74.5%) of dentists were willing to use nitrous oxide as a BMT. However, only 6% were utilizing nitrous oxide sedation and providing it to their child patient if indicated. The main reasons for this huge gap are lack of facilities/equipment and lack of training as indicated by the dentists. This study showed that parents are accepting nitrous oxide sedation as a BMT for their children. It also showed the willingness of the dentists to provide such BMT to their patients. The lack of training and lack of equipment are the main barriers to providing such service to the patients. More training courses and more facilities should be provided to eliminate such barriers.

Use of general anaesthesia in paediatric dentistry: barriers to discriminate between true and false cases

PURPOSE

The use of general anaesthesia (GA) has shown significant increase in child dental patients. This study aimed to assess whether behaviour management strategies can be the effective methods for decreasing the need for GA and its over-utilisation in paediatric dentistry.

METHODS

The patients (n = 240) aged 3-6 years old were selected from referrals by paediatric dentists (PD) or general dentists (GD) for dental treatment under GA. Each child's behaviour during first and subsequent appointments was assessed using the Frankl Behaviour Rating Scale. A first visit included clinical examination and fluoride therapy. In all sessions, a hierarchy of anxiety-reducing behaviour guidance strategies was implemented over nine steps in a logical treatment order.

RESULTS

Overall, 47.5% of children referred for dental treatments under GA were retrained to be treated routinely. False referrals were significantly higher in GD compared to PD group. 80.0% of the referred children by PD and 6.7% of those referred by GD were true GA cases and still needed GA. 20.1% of retrained children and 67.4% of true GA cases received conscious sedation. There was no significant change in the frequency of children considered uncooperative as the years of experience increased among GD, while this value was significant for PD.

CONCLUSIONS

The findings may highlight the importance of using behaviour management techniques thoroughly prior to referring an uncooperative child for treatment under GA, and may discourage its over-utilisation. Specifically, these skill sets and their efficient practice should be improved among general dentists.

Predicting children's behaviour during dental treatment under oral sedation

AIMS

The primary aim of this study was to assess whether parents' own anxiety and their perception of their child's dental fear and child's general fear can predict preoperatively their child's behaviour during dental treatment under oral sedation. The secondary aim was to assess whether the child's age, gender and ASA classification grade are associated with a child's behaviour under oral sedation.

STUDY DESIGN

Cross-sectional prospective study.

METHODS

The Corah's Dental Anxiety Scale (DAS), Children's Fear Survey Schedule Dental-Subscale (CFSS-DS) and Children's Fear Survey Schedule Short-Form (CFSS-SF) questionnaires were completed by parents of children undergoing dental treatment with oral midazolam. Behaviour was rated by a single clinician using the overall behaviour section of the Houpt-Scale and scores dichotomised into acceptable or unacceptable behaviour. Data were analysed using χ (2), t test and logistic regression analysis.

RESULTS

In total 404 children (215 girls, 53 %) were included, with the mean age of 4.57 years, SD = 1.9. Behaviour was scored as acceptable in 336 (83 %) and unacceptable in 68 (17 %) children.

STATISTICS

The level of a child's dental fear, as perceived by their parent, was significantly associated with the behaviour outcome (p = 0.001). Logistic regression analysis revealed that if the parentally perceived child's dental fear (CFSS-DS) rating was high, the odds of the child exhibiting unacceptable behaviour under oral sedation was two times greater than if their parents scored them a low dental fear rating (OR 2.27, 95 % CI 1.33-3.88, p = 0.003).

CONCLUSIONS

CFSS-DS may be used preoperatively to help predict behaviour outcome when children are treated under oral sedation and facilitate treatment planning.

An audit of the use of intravenous ketamine for paediatric dental conscious sedation

AIM

An audit of the use of intravenous ketamine for the provision of conscious sedation in paediatric dentistry was carried out over a three-year period. AUDIT DESIGN: In the audit, 3,751 children were treated and an evaluation was carried out for safety and effectiveness of the drug and procedure, the quality of sedation and clinical procedures provided. In addition, the occurrence of any adverse effects and parental satisfaction were noted along with recovery. All children were ASA I and II, with an average age of 7.5 years. Children were referred because of management problems and were assessed to be at the high anxious level of four and five on the Venham scale. A weight related 0.25 mg/kg was initially administered with additional increments of 0.25 mg/kg given if required. The average total dose provided was 0.41 mg/kg.

RESULTS

The majority of children (76%) accepted all treatment with no problems, with 19% experiencing a small amount of resistance. Although a range of dental treatment was provided, it was mostly exodontias of carious primary dentition. A 27% response was provided assessing satisfaction which was very favourable. No adverse reactions occurred although the most common postoperative experience was nausea.

CONCLUSION

This audit demonstrated the safety and effectiveness of using intravenous ketamine for paediatric conscious sedation and implications for training and appropriate service delivery were discussed.

Reported side effects of intravenous midazolam sedation when used in paediatric dentistry: a review

BACKGROUND

Intravenous (IV) midazolam may be of value as an alternative paediatric dental sedation technique, but there is some apprehension concerning its routine use due to a lack of evidence regarding its safety and side effects.

AIM

To review all available literature reporting the side effects of IV midazolam in children undergoing dental procedures.

DESIGN

Both randomised controlled trials (RCT) and non-randomised studies were reviewed. Reported side effects were categorised as either significant or minor, and the percentage prevalence of significant or minor side effects per episode of treatment was calculated.

RESULTS

Five RCTs were included, in which no significant side events were reported; however, minor side effects were recorded (n = 33, 19.5%), with paradoxical reaction being the most common (n = 11, 6.5%). Six non-randomised studies were included, in which no significant side effects were reported; however, minor side effects were reported (n = 118, 16.8%) with paradoxical reaction being the most common (n = 89, 12.7%).

CONCLUSIONS

Although no significant side effects were recorded, of the minor side effects reported paradoxical reaction was the most common. Due to inconsistency in side effect reporting, the authors suggest the application of a standardised adverse event reporting tool for future studies of sedation in paediatric dentistry.

Current UK dental sedation practice and the 'National Institute for Health and Care Excellence' (NICE) guideline 112: sedation in children and young people

AIM

Describe current dental sedation practice for under 19-year-olds in the UK and compare it with the recommendations of NICE guidance 112.

METHOD

Members of the Society for the Advancement of Anaesthesia in Dentistry and members of the Dental Sedation Teachers Group were invited to participate in an online survey.

RESULTS

Two hundred and sixty-six dentists and doctors completed the survey. Eighty-two percent were operator and sedationist (operator-sedationist). Ninety-five percent provided written information and 94% obtained written consent. Eighty-four percent kept a written or electronic sedation record. Eighty-six percent complied with life support training expectations. Eighty-six percent had immediate access to resuscitation equipment. Sixty-seven percent of sedationists reported that treatment could not be completed under sedation for <10% of cases during the previous year. When sedation was unsuccessful, 61% said they would schedule general anaesthesia and 54.5% would schedule advanced sedation care. Forty-nine percent believed that a dentist was an appropriate person to provide advanced sedation for 12-18 years. Only 24% thought a dentist should provide advanced sedation for children<12 years, with 75% preferring an anaesthetist. The appropriate setting for advanced sedation was thought to be primary care by 33% and secondary care by 68%.

CONCLUSIONS

We found good agreement between the current practice of sedation and the recommendations of the NICE guidance 112.

Dental patient anxiety: Possible deal with Lavender fragrance

Objective:

The pure essence of plants (essential oils) provides both psychological and physiological benefits when used accurately and safely. Conventionally, Lavender oil is known for relaxing, carminative, and sedative effects. Hence, an attempt was made to know the effect of Lavender essential oil on dental patient anxiety.

Methods:

The present study included two comparison groups (Lavender and control group), each comprising five dental clinics. In Lavender group, the ambient odor of Lavender essential oil was maintained with the help of a candle warmer in the reception area and in the control group, candle warmer with normal water was used. A total of 597 patients, aged above 18 years were included. A questionnaire comprising demographic information, and a modified dental anxiety scale was given to the patients in waiting room, and data regarding anxiety levels was recorded.

Findings:

Student's t-test (unpaired) showed a significant reduction in anxiety scores of Lavender group compared with the control group. Analysis of variances test showed reduction in anxiety scores as age increased in Lavender group.

Conclusion:

Fragrance of Lavender oil at reception area may effectively reduce the patient's state or current anxiety. This practice on routine usage can improve the quality of dental treatments.

An evaluation of intranasal sufentanil and dexmedetomidine for pediatric dental sedation

Conscious or moderate sedation is routinely used to facilitate the dental care of the pre- or un-cooperative child. Dexmedetomidine (DEX) has little respiratory depressant effect, possibly making it a safer option when used as an adjunct to either opioids or benzodiazepines. Unlike intranasal (IN) midazolam, IN application of DEX and sufentanil (SUF) does not appear to cause much discomfort. Further, although DEX lacks respiratory depressive effects, it is an α2-agonist that can cause hypotension and bradycardia when given in high doses or during prolonged periods of administration. The aim of this feasibility study was to prospectively assess IN DEX/SUF as a potential sedation regimen for pediatric dental procedures. After IRB approval and informed consent, children (aged 3-7 years; n = 20) from our dental clinic were recruited. All patients received 2 μg/kg (max 40 μg) of IN DEX 45 min before the procedure, followed 30 min later by 1 μg/kg (max 20 μg) of IN SUF. An independent observer rated the effects of sedation using the Ohio State University Behavior Rating Scale (OSUBRS) and University of Michigan Sedation Scale (UMSS). The dentist and the parent also assessed the efficacy of sedation. Dental procedures were well tolerated and none were aborted. The mean OSUBRS procedure score was 2.1, the UMSS procedure score was 1.6, and all scores returned to baseline after the procedure. The average dentist rated quality of sedation was 7.6 across the 20 subjects. After discharge, parents reported one child with prolonged drowsiness and one child who vomited at home. The use of IN DEX supplemented with IN SUF provided both an effective and tolerable form of moderate sedation. Although onset and recovery are slower than with oral (PO) midazolam and transmucosal fentanyl, the quality of the sedation may be better with less risk of respiratory depression. Results from this preliminary study showed no major complications from IN delivery of these agents.

An inhalation sedation patient profile at a specialist paediatric dentistry unit: a retrospective survey

AIM

To report on the characteristics, treatment, attendance, scheduling and duration of treatment sessions of child patients attending a specialist paediatric dental hospital service for inhalation sedation.

METHODS

A retrospective study was carried out of all 88 patient case notes of inhalation sedation recipients between September 2004 and March 2005. The recorded data included: child's age, gender and level of social deprivation together with the details of the treatment that was undertaken, the time between the first and current/last sedation appointment and the total number of appointments attended, cancelled and missed.

RESULTS

Twenty of the subjects were excluded giving a sample of 68; 51% male, mean age at start of treatment 9.8 years (range 4 to 15) and mean age at end of treatment 10.6 years (range 4 to 16). Of these children 35 (51%) were socially deprived. In respect to treatment, 29% had extractions, 22% endodontics, 81% restorations and 25% fissure sealants. In respect to the number of quadrants that had teeth requiring treatment; 26.5% had one, 25% two, 22% three and 26.5% four. The mean number of treatment sessions required was 4.4 with a mean duration between first and last appointments of 9.5 months (range 0.25 051). There were 27% of appointments cancelled, while 12% of patients failed to keep their appointments.

CONCLUSIONS

Although over half of the children treated under inhalation sedation came from socially deprived areas, attendance was reasonable and the majority required less than 5 appointments for treatment completion. The treatment provided was variable not only in respect to the procedures but also to the number of quadrants treated.

Effectiveness of Oral Midazolam for Paediatric Dental Care: A retrospective study in two Specialist Centres

AIM

To analyse retrospectively the outcomes for children undergoing oral care under conscious sedation with oral midazolam and local analgesia at Leeds dental Institute, England and Westmead Dental Hospital, Sydney, Australia. Secondly, the study assessed the suitability of oral midazolam for paediatric dental treatment.

STUDY DESIGN

Retrospective study of clinical outcomes based on dental records.

METHODS

All children included in the study had been treated between September 2000 to August 2004 and full dental records were available. The dental records were examined using a standard pro forma sheet and data collected for: age, previous behaviour using the Frankl [1962] scale, units of work planned and achieved using the modified index of O'Sullivan and Curzon [1991], midazolam dosage and treatment outcome.

RESULTS

The study population consisted of 101 children aged 1-11 years in both Leeds (57 children) and Westmead (44 children). There were significant differences between Leeds and Westmead with respect to age (mean +/-SD) in years 5.0+/-1.0 versus 2.9+/-1.6; number of treatment visits 1.7 versus 1.1; sedation dose used 0.5-0.7 mg/kg versus 02.-0.3; type and amount of treatment planned 8.3 units versus 3.3 and achieved 7.5 versus 2.2, for both centres respectively. There was also a difference in overall success rates of rendering the children dentally fit of 65% v. 91%, respectively.

CONCLUSION

Oral midazolam was found to be a useful drug for the management of young children with behaviour problems. It was found, however, not to be effective in all cases and for the provision of all types of paediatric dentistry. The results indicate that, when using oral midazolam in children, the treatment should be restricted to simple restorations and extractions over a maximum of two visits.