Assessing the sedative effect of oral vs submucosal meperidine in pediatric dental patients

Crossover Studies of Pediatric Dental Sedation are Inappropriate

Crossover studies continue to be published in spite of warnings about their inherent risks in relation to behavioral outcomes. This study took the opportunity of access to secondary data analysis in order to demonstrate the impact of a crossover design on the outcomes of randomized clinical trials aimed at the behavior of children during dental treatment. We evaluated the effect of the sequence of sedative administration, the sedative and the participant's age on the behavior of children undergoing two sequential dental visits. Eighteen uncooperative healthy young children were equally randomly assigned to: (G1) 1.0 mg/kg oral midazolam (first session) and oral placebo (second session); (G2) oral placebo (first) and 1.0 mg/kg oral midazolam (second). One trained observer assessed children's behavior. Data were analyzed by three-way mixed ANOVA. Both midazolam [mean(SD); 71.7%(16.5)] and placebo [48.6%(33.1)] produced more struggling behavior when they were administered in the first session compared to the second one (p=0.001). For the placebo, children aged 2-3 years exhibited more struggling behavior [G1 54.9%(36.2); G2 80.5%(8.3)] than those aged 4-5 years (p=0.04). Also, the reduction of percentage of struggling behavior was higher in G1 for older children (76.2%) and in G2 for younger children (32.9%). There were significant interactions between drug and sequence of administration, and between drug and age. The results of our study confirm the conventional wisdom that crossover study design is inappropriate to evaluate children's behavior/anxiety related-dental treatment under sedation and the results of crossover studies of dental sedation should be treated with extreme caution.

What is the level of evidence for the amnestic effects of sedatives in pediatric patients? A systematic review and meta-analyses

Background

Studies have suggested that benzodiazepines are amnestic drug par excellence, but when taken together, what level of evidence do they generate? Are other sedatives as amnestic as benzodiazepines? The aim of this study was to assess the level of scientific evidence for the amnestic effect of sedatives in pediatric patients who undergo health procedures.

Methods

The literature was searched to identify randomized controlled trials that evaluated anterograde and retrograde amnesia in 1-19-year-olds who received sedative drugs during health procedures. Electronic databases, including PubMed, Scopus and Cochrane Library besides clinical trial registries and grey literature were searched. Two independent reviewers performed data extraction and risk of bias assessment using the Cochrane Collaboration's Tool. The meta-analyses were performed by calculating relative risk (RR) to 95% confidence intervals (CI). The quality of the evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation approach.

Results

Fifty-four studies were included (4,168 participants). A higher occurrence of anterograde amnesia was observed when benzodiazepines, the most well-studied sedatives (n = 47), were used than when placebo was used (n = 12) (RR = 3.10; 95% CI: 2.30–4.19, P<0.001; I² = 14%), with a moderate level of evidence. Higher doses of alpha2-adrenergic agonists (clonidine/dexmedetomidine) produced more anterograde amnesia than lower doses (n = 2) (RR = 1.83; 95% CI: 1.03–3.25; P = 0.038; I² = 0%), with a low level of evidence; benzodiazepines’ amnestic effects were not dose-dependent (n = 3) (RR = 1.54; 95% CI: 0.96–2.49; P = 0.07; I² = 12%) but the evidence was low. A qualitative analysis showed that retrograde amnesia did not occur in 8 out of 10 studies.

Conclusions

In children, moderate evidence support that benzodiazepines induce anterograde amnesia, whereas the evidence for other sedatives is weak and based on isolated and small studies. Further clinical trials focused on the amnesia associated with non-benzodiazepine sedatives are therefore needed.

Trial registration

PROSPERO CRD42015017559.

How Do Observational Scales Correlate the Ratings of Children's Behavior during Pediatric Procedural Sedation?

Background. There is little information regarding the ability of observational scales to properly assess children's behavior during procedural sedation. Aim. To evaluate the characteristics of the Houpt scales, the Ohio State University Behavioral Rating Scale (OSUBRS) and the Venham Behavior Rating Scale when applied to preschool children undergoing conscious dental sedation. Design. This study included 27 children, 4–6 years old with early childhood caries that participated in a clinical trial (NCT02284204) that investigated two sedative regimes using oral midazolam/ketamine. Dental appointments were video-recorded; five calibrated observers assessed 1,209 minutes of video recording to score the children's behavior, following the instructions of the investigated scales. Data were analyzed by descriptive analysis and Spearman correlation tests (P < 0.05). Results. The Houpt overall behavior and the Venham scale were highly correlated (rho = −0.87; P < 0.001). OSUBRS scores were better correlated with Houpt overall behavior and Venham ratings, when compared to Houpt scores in the categories for movement and crying. Conclusions. The Houpt overall behavior and the Venham scores are global scales that properly measure children's behavior during dental sedation. Continuous assessment with OSUBRS through videos has a chance to give more precise data, while the Houpt categories can easily demonstrate children's behavior during procedures.

Comparative evaluation of bispectral index system after sedation with midazolam and propofol combined with remifentanil versus ketamine in uncooperative during dental procedures

Background:

Proper analgesic agents should be used in combination with sedative agents. Remifentanil is a synthetic narcotic/analgesic agent with a short duration effect and decreases the risk of apnea during recovery. Bispectral index system (BIS) is a new noninvasive technique for the evaluation of the depth of sedation. The aim of present clinical trial was to evaluate and compare the efficacy of intravenous sedation with propofol/midazolam/remifentanil (PMR) in comparison to propofol/midazolam/ketamine (PMK) for dental procedures in children 3-7 years of age.

Materials and Methods:

In this clinical trial, 32 healthy uncooperative children who were candidates for dental treatments under sedation were randomly divided into two groups. Intravenous sedation was induced with PMR in one group and with PMK in the other group. After injection and during procedure BIS index, heart rate and respiratory rate, blood pressure, and oxygen saturation was evaluated every 5 min. After the procedure, recovery time was measured. Data were analyzed with ANOVA, Friedman, Wilcoxon, and t-test.

Results:

The BIS value was significantly low in ketamin group (P = 0.003) but respiratory rates and heart rates were same in both groups with no statistical difference (P = 0.884, P = 0.775). The recovery time was significantly shorter in remifentanil group (P = 0.008 and P = 0.003).

Conclusion:

It can be concluded that intravenous sedation technique with PMR combination induces effective and safe sedation, with less pain and more forgetfulness and a shorter recovery time for children 3-7 years of age during dental procedures.

Comparison of Oral and Intranasal Midazolam/Ketamine Sedation in 3-6-year-old Uncooperative Dental Patients

Background and aims. There are several known sedative drugs, with midazolam and ketamine being the most commonly used drugs in children. The aim of this study was to compare the effect of intranasal and oral midazolam plus ketamine in children with high levels of dental anxiety.

Materials and methods.A crossover double-blind clinical trial was conducted on 23 uncooperative children aged 3-6 (negative or definitely negative by Frankel scale), who required at least two similar dental treatment visits. Cases were randomly given ketamine (10 mg/kg) and midazolam (0.5 mg/kg) through oral or intranasal routes in each visit. The sedative efficacy of the agents was assessed by an overall success rate judged by two independent pediatric dentists based on Houpt’s scale for sedation. Data analysis was carried out using Wilcoxon test and paired t-test.

Results. Intranasal administration was more effective in reduction of crying and movement during dental procedures compared to oral sedation (P<0.05). Overall behavior control was scored higher in nasal compared to oral routes at the time of LA injection and after 15 minutes (P<0.05). The difference was found to be statistically significant at the start and during treatment. However, the difference was no longer significant after 30 minutes, with the vital signs remaining within physiological limits. Recovery time was longer in the intranasal group (P<0.001) with a more sleepy face (P=0.004).

Conclusion.. Intranasal midazolam/ketamine combination was more satisfactory and effective than the oral route when sedating uncooperative children.