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

Sedative and behavioral effects of atomized intranasal midazolam in comparison with nebulized midazolam for children undergoing dental treatment: A randomized clinical trial

BACKGROUND

Fear and anxiet are significant barriers of dental care in children. Sedation emerged as a valuable behaviour guidance technique to manage uncooperative children.

AIM

To evaluate the sedative and behavioral effectiveness of midazolam administered via nebulizer in comparison with intranasal atomizer in the behavior management of anxious children during dental treatment.

STUDY DESIGN

Two-arm randomized clinical trial with 68 children (3-5 years) assigned to receive nebulized midazolam (NEB MDZ) and atomized intranasal midazolam (AIN MDZ) during dental treatment. The onset time, sedation levels, and behavior of children were documented. The data were analyzed using the Wilcoxon signed-rank test and Mann-Whitney U tests.

RESULTS

Significant differences between the two groups in terms of onset time, sedation level, and behavior of children during the dental treatment. AIN MDZ was associated with a significantly faster onset time compared with NEB MD, (p < .001). Children who received NEB MDZ exhibited deeper levels of sedation compared with AIN MDZ group (p = .02). During the administration of local anesthesia, notable statistical differences were observed between the behavior of the two groups (p = .02).

CONCLUSIONS

Midazolam administered via either nebulizer or intranasal atomizer was the effective route of administration and proved effective in the management of anxious children undergoing dental treatment. AIN MDZ, however, exhibited a faster onset time, whereas children receiving NEB MDZ demonstrated superior behavior compared with those receiving AIN MDZ.

Evaluation of the Efficacy of Buccal Midazolam in Comparison With Intranasal Midazolam Sedation in Uncooperative Children During Dental Treatment

Aim: Behavioral management techniques are not always sufficient, and then it is necessary to use pharmacological management methods. The aim of this study is to compare the effectiveness of buccal midazolam sedation with intranasal midazolam in non-cooperative children during dental treatment. Materials and Methods: A randomized single blinded comparative clinical study consisted of 40 children aged 3-6 years who were divided randomly into two groups: Group A intranasal midazolam and Group B buccal midazolam. The onset time of action and recovery time from sedation were compared between the two groups, and the efficacy of sedation was evaluated by Houpt behavior scale. The independent student's T test, Mann-Whitney U test, the Wilcoxon test and the Chi-square test were used. Results: There were no statistically significant differences in the onset time of action (p=0.458) and recovery time from sedation (p=0.148). There were no statically significant differences between the two groups in sleeping, crying, and movement categories (p=0.747), (p=0.183), (p=0.732), respectively, or in the overall Houpt scale (p=0.393), there were statistically significant differences in the sleep variable between the two studied phases in the intranasal group (p=0.014) and in the movement variable in the buccal group (p=0.039). Conclusion: Both buccal midazolam and intranasal sedation were effective in the management of uncooperative children during dental treatment at 85% and 80%, respectively. Trial Registration: Australian New Zealand Clinical Trials Registry: ACTRN12624000945527.

Evaluating the Quality of Systematic Reviews on Pediatric Sedation in Dentistry: An Umbrella Review

Sedation is a depression of a patient's state of consciousness, induced by medications, that can reach different levels of intensity during a medical procedure. Conscious sedation produces a minimally depressed level of consciousness without impairment of the ability to maintain an open airway, of protective reflexes or of responses to verbal and physical stimulation. This umbrella review is aimed at critically assessing the available systematic reviews (SRs) and meta-analyses (MA) on sedation in children/adolescents. An electronic database search was conducted that included Pubmed-Medline, Web of Science, Cochrane, Scopus, Scielo, Embase, LILACS and TRIP and the scope of which extended until January 2023. The risk of bias (RoB) of SRs was analyzed using the Measurement Tool to Assess SRs criteria 2 (AMSTAR2). Of 998 entries, 37 SRs were included. In terms of methodological quality, eight studies were assessed as having critically low quality, four studies had low quality, nine studies had moderate quality, and sixteen were considered to be of high quality. Based on the current guidelines, the most employed drugs in pediatric dentistry for sedation are nitrous oxide and midazolam; however, the available evidence supporting their use is insufficient and of low/critically low quality. The combined technique is recommended (nitrous oxide (30-50%) + midazolam). The optimal dose of oral midazolam is 0.75 mg/kg. The level of methodological quality of SRs is expected to increase according to the results and future directions of this umbrella review.

Efficacy of Preemptive Analgesia on Pain Perception After Simple Tooth Extraction: A Prospective Study

Background and objective This study aims to explore the concept of preemptive analgesia, which is the technique of administration of analgesic agents before the painful stimulus. This bridges the time gap between the onset of action of the analgesic agents and the wear-off of local anesthesia. Existing literature also brings up the concept of central sensitization, which is the hyper-activity of the nervous system in response to a noxious stimulus. Administration of preemptive analgesia prevents central sensitization and hence provides prolonged analgesia to the patient. For the benefit of this study, tab. Etoricoxib 90 mg was used as the analgesic agent. In addition, this study aims to investigate the effects of the administration of tab. Etoricoxib 90 mg 30 minutes before extraction of a single mandibular third molar on the effects of pain experienced by the patient after tooth extraction as compared to a placebo. Methodology This was a double-blinded, prospective, observational study. The pain experienced by 50 participants in each group was measured at 1 hour, 6 hours, 12 hours, and 24 hours postoperatively using a visual analog scale (VAS). The independent samples t-test was then conducted to evaluate the results and draw out conclusions. Results The average difference in pain experienced was maximum in the first hour after the procedure. The mean VAS score reported by patients was 3.14 in the study group but was 6.40 in the control group within the first hour. This difference was reduced in the first six hours after the procedure, with the average score being 3.82 in the study and 7.16 in the control group. The difference was the least after 12 hours, with the study group experiencing a VAS score of 4.64 and controls experiencing a VAS score of 6.14. After the first 24 hours, the mean VAS score was 3.80 in the study group and 5.60 in the control group. Conclusions Preemptive administration of tab. Etoricoxib 90 mg can reduce postextraction pain in healthy adult patients as compared to placebo tablets, with a maximum difference in pain reduction seen at the end of the first six hours (P = 0.012) and the minimum at the end of 12 hours (P = 0.0197).

A Comparative Study of Parent and Child Perspectives on Using the Intranasal Mucosal Atomization Device for Behavior Management in Pediatric Dental Sedation

Background Dental anxiety in children often necessitates sedation for effective treatment. Different methods of sedation have proved to be beneficial. However, intranasal sedation provides a needleless, rapid drug delivery method that bypasses hepatic metabolism. Intranasal sedative drugs can be delivered using a mucosal atomization device (MAD). This study aimed to find the opinions, beliefs, and existing knowledge of parents and children regarding intranasal sedation and the method of drug delivery through MAD. Materials and methods The study comprised 50 parents, aged 20 to 50, who came in with a single child, aged five to nine years. In separate rooms, parents and kids were each shown a video about the use of the intranasal sedation technique with MAD as a pharmaceutical help during routine dental procedures. After the video presentation, each participant was required to complete a pretested self-made questionnaire with 21 questions and multiple-choice options. The chi-square test was used in the statistical analysis of the completed questionnaires (P < 0.05). Paired t-test was used for behavior assessment of the children before and after intranasal sedation. Results A significant correlation between parental socioeconomic status and acceptance of intranasal sedation was observed. Parents with higher education levels exhibited a greater level of acceptance (P = 0.000). Parents whose children had prior dental experiences were more likely to view intranasal sedation as a safe option (P = 0.038). Additionally, a significant proportion of previously sedated children expressed willingness to undergo treatment using intranasal sedation. Evaluation of children's behavior before and after treatment revealed a notable improvement, indicating the effectiveness of intranasal sedation (P = 0.000). Conclusion The study thoroughly investigated how parents and children view intranasal sedation via MAD. It revealed a positive perception of safety and trust among parents regarding this method for pediatric dental procedures.

Comparative evaluation of intranasal dexmedetomidine, intranasal midazolam, and nitrous oxide for conscious sedation of anxious children undergoing dental treatment: A randomized cross-over trial

BACKGROUND

Pharmacological methods, specifically sedatives, have gained popularity in managing the behavior of children during dental appointments.

AIM

The aim of this study was to compare 1 m/kg intranasal dexmedetomidine, 0.3 mg/kg intranasal midazolam, and nitrous oxide in evaluating the level of sedation, behavior of the child, onset of sedation, physiologic signs, and adverse effects.

MATERIALS AND METHODS

In this cross-over trial, 15 children aged 6-8 years were randomized to receive intranasal atomized dexmedetomidine, intranasal atomized midazolam, and inhalation nitrous oxide at three separate visits. After administering the sedative agent, a single pulpectomy was performed during each appointment, and the outcomes were recorded. The washout period between each visit was 1 week.

RESULTS

All three sedative agents were equally effective in controlling overall behavior. Dexmedetomidine showed lower sedation level scores (agitated; score 9) than the other groups. There was a statistically significant difference in the onset of sedation, with dexmedetomidine having the longest onset of 36.2 ± 9.47 min. Coughing and sneezing were predominantly observed after administration of intranasal midazolam. Oxygen saturation levels were statistically lower in the intranasal midazolam group during local anesthesia administration and post-treatment.

CONCLUSION

0.3 mg/kg intranasal midazolam is as effective as nitrous oxide sedation for controlling behavior and providing adequate sedation in pediatric dental patients. However, 1 m/kg dexmedetomidine did not provide the same level of sedation and had a significantly longer onset. 0.3 mg/kg intranasal midazolam is an effective alternative to nitrous oxide sedation in anxious children.

Rectal Sedation With Ketamine and Midazolam in the Management of Uncooperative Children During Dental Treatment: A Case Series and Method Description

Background In pediatric dentistry, sedation aims to eliminate anxiety to facilitate the completion of dental procedures. Sedation in children is a multidimensional field that includes the child, parents/guardians, and the health care team. The rectal route is generally painless, making it suitable for children who are afraid of needles. This route has several advantages over the oral route, including reduced patient cooperation requirements, a faster and more predictable onset, and less physical trauma than the intravenous and intramuscular routes. This case series aimed to evaluate the effectiveness and success rate of rectal sedation with ketamine and midazolam in the management of uncooperative children during dental treatment. Case presentation Ten healthy children with definitely negative behavior were enrolled in this study. Each child was given 7 mg/kg of ketamine in combination with midazolam 0.1 mg/kg by the rectal route. The mean onset sedation time was 9.5 minutes, and pulpotomy procedures were done. Behavioral response was monitored throughout treatment using the Ohio State University Behavioral Rating Scale (OSUBRS), and the depth of sedation was measured using the University of Michigan Sedation Scale (UMSS). The Houpt General Behavior Scale was used to estimate the treatment success rate based on the overall behavior rating. All 10 cases showed good anxiolysis and cooperation following rectal administration, with no side effects observed. Conclusions Rectal administration of ketamine in combination with midazolam may be considered a reliable method in the management of uncooperative children during dental treatment. No adverse effects were observed during or after the sedation procedure.

Parents' satisfaction and children's acceptance of nasal compared to oral midazolam for sedation in two consecutive pediatric dental treatments: a randomized controlled study

Introduction

Midazolam, by either the oral or the nasal route, is safe and effective in reducing anxiety and improving behavior in children during dental procedures.

Aim

To compare both children's acceptance and parents' satisfaction with midazolam premedication, when administered as an oral syrup or as a nasal spray and explore whether there were positive or negative changes in acceptance during consecutive dental treatment visits.

Methods

Randomized controlled study among uncooperative 2-6-year-old children who needed at least two similar dental treatments. On each visit, the acceptability of the medication was assessed as good, fair, or poor. The duration of crying after medication administration was recorded. Additionally, parents were asked to rank their satisfaction with the mode of administration.

Results

The study group included 60 children; 30 patients received midazolam orally and 30 nasally. Route of administration did not correlate with medication acceptance in the first (p = 0.11) and second visit (p = 0.61). However, in the oral group, medication acceptance of 73% of children deteriorated on the second visit, compared to 33% in the nasal group (p = 0.01). Parents of children in the oral group expressed less satisfaction with premedication administered on the second visit than did parents of children in the nasal group, p = 0.00. Poor medication acceptance at the first visit (p = 0.014) and oral route of administration (p = 0.014) were found to be predictors of poor medication acceptance at the second visit.

Conclusions

Acceptance of premedication is expected to deteriorate after the first treatment visit, especially in the oral route of administration. Dentists should consider nasal spray administration for young pediatric patients who need more than one dental treatment. Parents should be prepared for possible resistance or refusal by children.

Clinical Trial Registration

ClinicalTrials.gov, identifier NCT02679781.

Influence of Temperament on the Acceptance of Two Conscious Sedation Techniques in Toddlers Undergoing Dental Treatment: A Randomised Cross Over Trial

Background

Pediatric dentists often find it challenging to handle pediatric patients due to their fear, unease, and anxiety toward dental procedures. To address this, sedation agents such as intranasal midazolam and nitrous oxide are commonly used as pharmacological behavior management methods. A child's temperament affects their behavior in unfamiliar settings.

Aim

To study the effect of child temperament on the acceptance of the nasal mask and intranasal drug administration in children undergoing dental treatment.

Methods

Thirty-two anxious children aged three to five were randomly assigned to two groups. During the first visit, one group received intranasal midazolam sedation, while the other group received nitrous oxide administered through a mask. On the subsequent visit, the groups crossed over. The parent assessed the child's temperament, and the acceptance of the sedation methods was recorded. The Ohio State University Behavioral Rating Scale (OSUBRS) was employed to assess behavior during the administration of local anesthesia. Statistical analysis was carried out using the chi-square test and Mann-Whitney U test (p value <0.05).

Results

Children exhibited greater acceptance of the nasal mask compared to using the intranasal route for delivering midazolam during the induction process. A significant statistical influence of temperament was observed on the acceptance of the nasal mask and the intranasal atomisation device (p value <0.05). The mean OSUBRS scores did not show any statistically significant differences between the sedation groups (p = 0.14).

Conclusion

Most children demonstrated a more favorable acceptance of the nasal mask during the induction process; however, intranasal midazolam can serve as an effective alternative for anxious patients who struggle to keep the nitrous oxide mask on during the dental procedure. The adoption of these methods is influenced directly by the child's temperament.

Assessment of Pain During Pediatric Dental Treatment Using Different Sedative Agents: A Crossover Trial

Background Behavioral management techniques are employed for children who are fearful and uncooperative. Pharmacologic sedation and anesthesia are frequently utilized to manage pain and anxiety in pediatric dental patients. Aim  To evaluate the intraoperative and postoperative pain levels during dental treatment of children sedated with 1.5 μg/kg intranasal dexmedetomidine, 0.3 mg/kg intranasal midazolam, and nitrous oxide. Materials and methods In this crossover study, 24 children between the ages of five and seven years were randomly assigned to receive intranasal atomized dexmedetomidine, intranasal atomized midazolam, and inhaled nitrous oxide during three different visits. At each visit, a single pulp therapy procedure was conducted after administering the respective sedative agent, and the pain levels were documented. There was a one-week interval between each visit to allow for a washout period. The data were analyzed using IBM SPSS Statistics for Windows, Version 22.0 (Released 2013; IBM Corp, Armonk, NY, United States) using the Wilcoxon signed-rank test and Kruskal-Wallis H test (p < 0.05). Results All three sedative agents were equally effective in controlling postoperative and intraoperative pain. Although there was no statistically significant difference among the groups, clinically, midazolam showed lower intraoperative pain levels (mean 1.78 ± 1.42). Conclusion  In pediatric dental patients, intranasal midazolam at a dosage of 0.3 mg/kg and intranasal dexmedetomidine at a dosage of 1.5 μg/kg demonstrate comparable effectiveness to nitrous oxide sedation in pain management. These options serve as effective alternatives for anxious children who may not tolerate nitrous oxide sedation.