Optimal and safe standard doses of midazolam and propofol to achieve patient and doctor satisfaction with dental treatment: A prospective cohort study

Background

The incidences of morbidity and mortality caused by pharmacosedation for dental treatment have not yet reached zero. Adverse events are related to inappropriate respiratory management, mostly originating from an overdose of sedatives. Since sedation is utilized for the satisfaction of both the dentist and the patient, the optimal dose should be minimized to prevent adverse events. We attempted to define the optimal doses of midazolam and propofol required to achieve high levels of patient and dentist satisfaction.

Methods

One thousand dental patients, including those undergoing third molar extractions, were enrolled in this study. A dose of 1 mg of midazolam was administered at 1-minute intervals until adequate sedation was achieved. Propofol was then infused continuously to maintain the sedation level. Both the patients and the dentists were subsequently interviewed and asked to complete a questionnaire. A multivariate logistic regression analysis was used to examine the factors that contributed to patient and dentist satisfaction.

Results

The peak midazolam dose resulting in the highest percentage of patient satisfaction was 3 mg. Both a lower dose and a higher dose reduced patient satisfaction. Patient satisfaction increased with an increasing dosage of propofol up until 4 mg/kg/hr, reaching a peak of 78.6%. The peak midazolam dose resulting in the highest percentage of dentist satisfaction (78.8%) was 2 mg. Incremental propofol doses reduced dentist satisfaction, in contrast to their effect on patient satisfaction. The strongest independent predictors of patient satisfaction and dentist satisfaction were no intraoperative memory (OR, 5.073; 95% CI, 3.532–7.287; P<0.001) and unintentional movements by the patient (OR, 0.035; 95% CI, 0.012–0.104; P<0.001), respectively. No serious adverse events were reported.

Conclusion

We found that 3 mg of midazolam and 3 mg/kg/hr of propofol may be the optimal doses for maximizing both patient and dentist satisfaction. Although this level of sedation is relatively light, memory loss and an absence of unintentional patient movements can be expected without adverse events.

Ontario Dentists' Estimation of Patient Interest in Anesthesia

OBJECTIVE

To investigate Ontario dentists’ perceptions of patient interest in sedation and general anesthesia (GA) during treatment and patient fear and avoidance of dental treatment.

METHODS

Using the Royal College of Dental Surgeons of Ontario roster, we randomly selected 3001 practising Ontario dentists, from among those who listed an email address, to complete a 16-question survey by mail or online. Demographic information (e.g., gender, size and type of primary practice, and years of experience) was collected as well as dentist reports of patient interest in sedation/GA and level of fear regarding treatment. Analysis included sample t-tests to compare Ontario dentist responses with patient responses to a 2002 national survey.

RESULTS

1076 dentists participated (37.9% response rate), comprised of 69.7% males, 84.4% general practitioners, 0.5–42 years of practice (mean 20.6 years), and 40.6% from cities with a population larger than 500,000. Dentists underestimated patients’ interest in sedation/GA, with dentists and patients reporting patients “Not interested” as 66.8% and 43.9%, respectively, and “Interested depending on cost,” 19.8% v. 42.3%. Dentists also underestimated patient interest in sedation/GA for specific dental procedures including scaling, fillings/crowns, root canal therapy and periodontal surgery (p < 0.01). Dentists overestimated patient fear levels (“Somewhat afraid,” 19.9% v. 9.8%; “Very afraid,” 10.6% v. 2.0%; “Terrified,” 6.0% v. 3.5%) and the proportion of patients avoiding dental care (13.3% v. 7.6%).

CONCLUSION

Dentists underestimate patients’ preference for sedation/GA and overestimate their fear and avoidance of dental care. The significant disparities between the views of dentists and patients may affect the availability and provision of sedation and general anesthesia in Ontario dental practices.

Perception of Non-surgical Periodontal Treatment in Individuals Receiving or Not Receiving Local Anaesthesia

PURPOSE

Patients might refuse the offer of local anaesthesia (LA) administration prior to dental treatment. This study investigates subjective discomfort perception during non-surgical mechanical periodontal therapy delivered with or without LA.

MATERIALS AND METHODS

Sixty patients with mild to moderate chronic periodontitis and prior periodontal debridement experience were randomly enrolled in nonsurgical therapy of a quadrant with or without LA administration. Patients were free to comply or not with the allocated LA arrangement. Visual analogue scales (VAS) of discomfort perception at various stages of the treatment as well as overall satisfaction were recorded. Demographic, psychosocial and periodontal parameters were recorded.

RESULTS

Thirty-one patients undergoing nonsurgical periodontal therapy not receiving (LA-) and 29 participants receiving LA (LA+) were studied. Compared to LA- patients, LA+ individuals perceived less discomfort during treatment and reported less dental anxiety (p<0.05). Lower overall treatment satisfaction was associated with prior unpleasant periodontal experience (p=0.047). Overall, debridement discomfort was associated with not receiving LA, noncompliance with the pain control regimen allocated, longer treatment duration, greater gingival inflammation and a higher percentage sites with probing pocket depths≥5 mm (p<0.05).

CONCLUSION

Clinicians should be aware that patients who refuse LA can experience higher dental anxiety and therefore may require various pain control strategies for comfort during nonsurgical periodontal therapy, which, if not employed, can lead to less periodontal treatment satisfaction.

A study of the provision of hospital based dental General Anaesthetic services for children in the North West of England: Part 2--the views and experience of families and dentists regarding service needs, treatment and prevention

BACKGROUND

Patterns of service delivery and the organisation of Dental General Anaesthesia (DGA) have been found to differ across hospitals. This paper reports on qualitative research aimed to understand the impact of such variation by exploring views and experiences of families receiving care in different hospital sites, as well as dentists involved in referral and delivery of care.

METHOD

Qualitative semi-structured interviews were conducted with 26 people comprising parents (n = 15), dentists working in primary care (n = 6) and operating dentists (n = 5) in relation to DGA. Participants were recruited from areas across the North West of England to ensure a variety referral and treatment experiences were captured. Field notes were made during visits to all settings included in the study and explored alongside interview transcripts to elicit key themes.

RESULTS

A variety of positive and negative impacts on children and parents throughout the referral process and operation day were apparent. Key themes established were clustered around three key topics: 1. Organisational and professional concerns regarding referrals, delivery of treatment and prevention. 2. The role of hospital environment and routine on the emotional experiences of children. 3. The influence of the wider social context on dental health.

CONCLUSION

These findings suggest the need and perceived value of: tailored services for children (such as play specialists) and improved information, such as clear guidance regarding wait times and what is to be expected on the day of the procedure. These features were viewed to be helpful in alleviating the stress and anxiety often associated with DGA. While some elements will always be restricted in part to the hospital setting in which they occur, there are several aspects where best practice could be shared amongst hospitals and, where issues such as wait times have been acknowledged, alternative pathways can be explored in order to address areas which can impact negatively on children.

Oral health-related quality-of-life in Swedish children before and after dental treatment under general anesthesia

OBJECTIVE

This study evaluated oral health-related quality-of-life (OHRQoL) in children and families before and after dental treatment under general anesthesia because of severe caries or molar-incisor hypomineralization (MIH).

MATERIALS AND METHODS

A consecutive sample of the parents/caregivers of children (3-14 years) in need of treatment under general anesthesia participated in the study. The children were divided into two groups: 3-6 years and 7-14 years. The 49-item questionnaire that was administered before and after general anesthesia comprised the Child Oral Health Quality of Life-components of the Parental-Caregivers Perception Questionnaire (P-CPQ), the Family Impact Scale (FIS) and two global questions concerning oral health and general well-being. The P-CPQ domains were Oral symptoms, Functional limitations, Emotional well-being and Social well-being. The FIS items assessed impact on family life.

RESULTS

In both age groups, a significant decrease (p < 0.001) occurred in overall P-CPQ and the Oral symptoms, Functional limitations and Emotional limitations domains of the P-CPQ. Mean values for the Social well-being domain decreased significantly in the older (p < 0.05) but not the younger age group. Mean values for FIS decreased significantly in the younger (p < 0.001) and the older (p < 0.05) age groups.

CONCLUSIONS

Dental treatment of severe caries or MIH, performed under general anesthesia, had an immediate effect on the oral health-related quality-of-life in the children in this study and a positive impact on the family situation.

Evaluating the advances and use of hypodermic needles in dentistry

Different injection techniques and patient management methodologies have been proposed to decrease the fear patients may have concerning dental needles. Dental providers should have an understanding of the technological advances, changes in techniques, and patient perceptions associated with the hypodermic needle. This article provides an overview of the pain perception process associated with dental injections. It reviews the two main sensory nerve fibers associated with injection pain and discusses needle properties as well as complications and adverse occurrences.

[Evaluation of psychological methods for determining the degree of psychological stress in children in dentistry]

The article deals with results of comparative evaluation of system of assessment of children's fear and anxiety in dentistry (SDS test) and other objective and subjective methods for assessing anxiety in pediatric patients. We studied 381 pediatric patients aged from 3 to 7 years. The aim of the study was to prove validity mathematical derived FCD test as a technique of anxiety detection in dentistry. During the study following subjective test were used: MAS, DAS, mYPAS, VAS, STAI, STAIC, EASI, PHBQ, and some history data and stress factors were also considered. Objective data used were vital signs (hemodynamics and respiratory rate). Test SDS has strong correlation with YALE, MAS, DAS, STAIlich, VAS and other parameters such as age, sex, person which is responsible for bringing up a child and so on.

Assessing change in quality of life and dental anxiety in young children following dental rehabilitation under general anesthesia

PURPOSE

This study's purpose was to investigate how young children's and parent/caregivers' oral health-related quality of life and children's dental fears were affected by dental rehabilitation under general anesthesia (DRGA).

METHODS

A consecutive clinical sample of dyads of parents/caregivers and their four- to six-year-old children who received DRGA were surveyed before and after DRGA. Parents/caregivers responded through a self-administered questionnaire [Early Childhood Oral Health Impact Scale (ECOHIS)], and children received a dentist-administered questionnaire [children's fear survey schedule-dental subscale (CFSS-DS)].

RESULTS

The final sample consisted of 311 children/caregiver dyads. One to six teeth were extracted in 91 percent of children. There was a 44 percent decrease in total ECOHIS scores following treatment (P<.001). Overall child impact section scores decreased 34 percent following treatment (P<.001), and family impact section scores decreased 65 percent (P<.001). CFSS-DS anxiety scores after dental treatment were significantly higher for 14 of 15 situations/conditions assessed (P<.001). There was a trend of higher CFSS-DS scores in children who received increasing numbers of extractions.

CONCLUSION

Children's and parent/caregivers' quality of life improved after the children received dental rehabilitation under general anesthesia, and children's fears increased for all situations tested. The number of extractions the children received was associated with increased levels of fear.

Treatment needs and adverse events related to dental treatment under general anesthesia for individuals with autism

Individuals with autism can be quite challenging to treat in a routine dental-office setting, especially when extensive dental treatment and disruptive behavioral issues exist. Individuals with autism may also be at higher risk for oral disease. Frequently, general anesthesia is the only method to facilitate completion of the needed dental treatment. General anesthesia is not without complications, and unique occurrences are a necessary consideration for special-needs populations. In addition, behavior challenges may occur which can be disruptive to hospital staff. This article describes treatment needs and determines adverse events during the perioperative period for individuals with autism who have had general anesthesia for comprehensive dental treatment in the hospital.

Assessing change in the family impact of caries in young children after treatment under general anaesthesia

OBJECTIVE

To examine the properties, validity and responsiveness of the Family Impact Scale in a consecutive clinical sample of patients undergoing dental treatment under general anaesthesia.

MATERIALS AND METHODS

A consecutive clinical sample of parents/caregivers of children receiving dental treatment under general anaesthesia provided data using the Family Impact Scale (FIS) component of the COHQOL(©) Questionnaire. The first questionnaire was completed before treatment, the follow-up questionnaire 1-4 weeks afterward. Treatment-associated changes in the FIS and its components were determined by comparing baseline and follow-up data.

RESULTS

Baseline and follow-up data were obtained for 202 and 130 participants, respectively (64.4% follow-up). All FIS items showed large relative decreases in prevalence, the greatest seen in those relating to having sleep disrupted, blaming others, being upset, the child requiring more attention, financial difficulties and having to take time off work. Factor analysis largely confirmed the underlying factor structure, with three sub-scales (parental/family, parental emotions and family conflict) identified. The parental/family and parental emotions sub-scales showed the greatest treatment-associated improvement, with large effect sizes. There was a moderate improvement in scores on the family conflict sub-scale. The overall FIS showed a large improvement.

CONCLUSION

Treating children with severe caries under general anaesthesia results in OHRQoL improvements for the family. Severe dental caries is not merely a restorative and preventive challenge for those who treat children; it has far-reaching effects on those who share the household and care for the affected child.

A clinician guide to patients afraid of dental injections and numbness

Fears of dental injections remain a clinical problem often requiring cognitive behavioural psychology counselling and sedation in order to carry out needed dental treatment. This study, based on a national survey in Australia, compared patient concerns about numbness caused by local anaesthesia and fears of the injection itself. It also examined associations between dental fearfulness and avoidance associated with patient self-reported negative experiences and treatment need. Clinical advice on how to approach such patients is offered. Relatively high levels of dental anxiety and fear have been reported in several industrialised Western societies (McGrath & Bedi, 2004; Armfield, Spencer & Stewart, 2006; Lahti et al., 2007; Enkling, Marwinski Jöhren, 2006). In the U.K., almost one in three adults consider themselves to always be anxious about going to the dentist (Nuttall et al., 2001). Of concern is that this dental fear may be passed on to the children of anxious adults (Nuttall, Gilbert & Morris, 2008), leading to an inter-generational perpetuation of the problem. There is considerable evidence that dental fear is related to poorer oral health, reduced dental attendance and increased treatment stress for the attending dentist. There are many aspects of going to a dentist that might elicit feelings of apprehension, concern or anxiety in prospective patients (Liddell & Gosse, 1998; Oosterink, de Jongh & Aartman, 2008). One of the most commonly reported concerns relates to receiving injections. Indeed, fear of needles and the treatment of injection fear has been an important focus of a research in the U.K. (Boyle, Newton & Milgrom, 2010). Needle fear, in particular, is a major issue given that the delivery of local anaesthesia via injection is the central plank of pain relief techniques in dentistry (Malamed, 2009) and dentists as well as patients often avoid difficult injections as a consequence, resulting in poor pain control. A less well described anxiety of receiving dental treatment is fear of numbness associated with the dental injection (Morse & Cohen, 1983). Certainly, many dentists believe that their patients avoid local anaesthesia because of a wish to avoid the disturbing effects of numbness (Moore et al., 1998). Milgrom et al. (1997) found that fears about the numbness associated with receiving local anaesthesia significantly differentiated avoiders and non-avoiders of dental treatment. However, these concerns appeared to be much less common than those concerning the perceived pain of injections and fear of bodily injury resulting from the injection (Milgrom et al., 1997; Kaako et al., 1998). Consistent with these findings, whereas 43% of English patients asked to imagine undergoing future third molar surgery expressed concerns primarily about pain, only 6% of patients indicated concern about numbness as their worst fear (Earl, 1994). More recently, a study of Dutch people found that the feeling of numbness from the anaesthesia was rated as the 41st most feared dental stimulus out of a list of 67 possible stimuli, and that only 1.5% of the general population regarded numbness as extremely anxiety provoking (Oosterink, de Jongh & Aartman, 2008). However, it is important for a clinician to differentiate between those who dislike the sensation of temporary numbness versus those who may worry that it may never wear off. Such problem thinking can be an issue irrespective of whether a patient overcomes the fear of needles with sedation or not. A large number of patients dislike the sensation of numbness enough for manufacturers to respond with a partial antidote in alpha adrenergic receptor antagonist phentolamine mesylate (OraVerse Sanofi-Aventis, Hersh & Lindemeyer, 2010). Approval of this agent, which shortens the length of soft tissue anaesthesia after inferior alveolar block, is pending in the UK and other European countries. In other cases, dentists resort to using local anaesthetics without vasoconstrictors to shorten the period of anaesthesia (Fiset, Getz, Milgrom & Weinstein, 1989). While the association between dental fear and fear of injections has received considerable attention, the relationship between dental fear and numbness has received less attention. In particular, the nature of the associations between dental fear and avoidance and anxiety over numbness has not been studied. There has also been no research into whether or not concerns over numbness are independent of injection concerns. Finally, the association between fear of numbness and injections and dental avoidance and treatment needs has not been investigated. This study, based on survey work in Australia, aimed to compare patient concerns about numbness caused by receiving anaesthesia to that of anxiety over the receipt of needles and injections. Associations with dental fear and avoidance as well as negative experiences and treatment needs were also explored.

Patients appreciation for information on anesthesia and anxiolysis in dentistry

AIM

The research regards information on anesthesia to patients undergoing oral surgery. Every patient evaluated the information received at the end of the preoperative visit and in the postoperative period.

METHODS

One hundred-fifty dental patients were asked about the most appreciated information received in the preoperative visit on the anxiolytic technique, local anesthesia and treatment of the perioperative pain. Afterwards the patients had to report on their reaction to the content of the preoperative visit and information quality. On a phone interview they had to evaluate their appreciation of the anxiolytic technique, their perception during loco-regional anesthesia and incidence of pain and edema.

RESULTS

The most appreciated details were those on the intervention, pharmacologic treatment, postoperative complicances, postoperative pain and operative competence; less appreciated were those on loco-regional anesthesia, duration of the intervention, anxiolytic techniques, hospital reception and permanence in the hospital. Ninety-eight percent of the patients considered to have been adequately informed on a context judged to be extraordinary (99.3%), 96.6% indicated the information as necessary, 98.6% appreciated the treatment of the intraoperative and postoperative (99.3%) pain and 99.3% the anxiolytic treatment. On the telephone interview, 100% of patients expressed satisfaction for the experienced intraoperative tranquillity, 91.3% complained for not having received in the past a similar preoperative visit, 99.3% wished a diffused application of the information. The loco-regional anesthesia was associated to psychological detachment in 84% of the cases and the incidence of postoperative pain was of 36%.

CONCLUSION

The information on the anxiolytic techniques, loco-regional anesthesia, treatment of perioperative pain and postoperative distress was enthusiastically accepted and albeit initially induced feelings of astonishment resulted to be appreciated and preferred in the whole of the patients.

Factors affecting preoperative anxiety in children undergoing general anaesthesia for dental rehabilitation

AIM

The primary aim was to examine anxiety levels, and to identify factors affecting preoperative anxiety among healthy children undergoing general anaesthesia for dental rehabilitation. A secondary aim was to assess parental distress and attitude to accompanying their children during this procedure.

STUDY DESIGN

Observational cross sectional study.

METHODS

Anxiety levels of 118 children admitted to the Day Case unit of King Abdullah teaching hospital in Irbid, Jordan, for dental rehabilitation under general anaesthesia (GA) were assessed at different phases (before and during induction of GA) using the Global Mood Score (GMS) with parental presence. The effect of certain variables such as age, sex, reason for referral, past GA experience, accompanying parent, and parental distress, on children's anxiety during this procedure were assessed using multivariate analysis. The level of significance was <0.05. Parental distress and attitudes to accompanying their children were assessed using a structured questionnaire.

RESULTS

There was a significant increase of child anxiety on GMS reaching its highest level in phase three (induction phase). A multivariate test (MANOVA) showed that previous experience of the child with GA, and reason for referral to dental rehabilitation under GA, significantly predicted child anxiety (P-value of 0.019 and 0.012) respectively. However, parental distress, accompanying person, age, and sex of the child, did not affect child anxiety. Parental distress was at its highest level in phase three, mothers were significantly more stressed than fathers and parental distress was significantly increased when a child was <5 years of age.

CONCLUSION

Factors contributing to increased child anxiety during induction of GA for dental rehabilitation were age, previous GA experience, and referral for GA at a very young age. Most parents, especially mothers, were distressed during the induction phase, therefore sufficient preoperative preparation of those children and parents is necessary to achieve best patient management.

[Fear of dental treatment among children. Influence of experience and psychological functioning]

This research considers whether fear of dental treatment among children is linked with a prior (negative) experience with local anaesthesia or with psychological functioning. Furthermore, the study investigated whether these factors play a role in anxious behaviour before and during a local anaesthetic injection. In this study 128 children between the ages of 4 and 11 took part. With the help of video recordings, the anxious behaviour before and during the local anaesthetic injection was scored using the Venham-scale. During the treatment one of the child's parents or guardians was asked if the child had previously been given a local anaesthetic injection (experience). The fear of dental treatment and the child's psychological functioning were measured using the parents' version of the 'Dental Subscale' of the 'Children's Fear Survey Schedule' and the 'Strengths and Difficulties Questionnaire' respectively. Results showed a correlation between on one hand fear of dental treatment and on the other hand anxious behaviour before and during a local anaesthetic injection and psychological functioning. Furthermore, results indicated that children with fear of dental treatment exhibited more fearful behaviour before and during an injection with local anaesthetic. Only in the case of children whose psychological functioning was reduced there was a significant relationship between experience with local anaesthesia and fearful behaviour prior to the injection of a local anaesthetic.

Preschool children and relative analgesia: satisfaction grading through a verbal questionnaire

AIM

The aim of the study was to assess 100 preschool children's satisfaction grading of relative analgesia (RA) after completing dental treatment by collecting their opinion on this technique through a verbal questionnaire.

METHODS

After completing dental care a simple verbal questionnaire (3 questions) was administered by the operator. The questionnaire investigated: 1) patient's satisfaction about the sedation treatment; 2) patient's agreement to re-experiment the technique and 3) patient's emotions while sedated. Moreover, following treatment, each child was invited to make a drawing on the experience.

RESULTS

Data obtained were classified in 3 groups: group 1 (87% of children) appreciated RA and would agree to repeat the experience; group 2 (4% of the sample) did not answer the verbal questionnaire and group 3 (9%) did not enjoy the sedation technique. Only 15 children completed a drawing; conducting a psychological analysis through C.R. Rogers' theory of Person Centred Approach coupled with the handwriting analysis methodology defined by Girolamo Moretti, positive features were found in the majority of the drawings (13 out of 15).

CONCLUSION

The majority (87%) of the sample appreciated to experience nitrous oxide inhalation sedation and would undergo a further appointment under RA.

Computerized anesthesia delivery system vs. traditional syringe: comparing pain and pain-related behavior in children

The aim of this study was to compare the behavioral reaction of children who receive local anesthesia with a traditional syringe with the behavioral reaction of children who receive local anesthesia with a computerized device (Wand) and to differentiate between the reactions of highly anxious children with those displaying low anxiety. One hundred and twenty-five children aged 4-11 yr were randomly allocated to receive local anesthesia with the Wand or a traditional injection. Parents completed the Dental Subscale of the Children's Fear Survey Schedule (CFSS-DS). Two independent observers scored videotapes of the anesthesia in 15-s intervals. The occurrence of muscle tension, crying, verbal protest, movement, and resistance was registered and a score was given on the Venham distress scale. The mean injection time with the Wand was four times as long as with the traditional syringe. During the first 15 s of the injection, low-anxious children receiving local anesthesia with the Wand displayed less muscle tension, less verbal protest and less movement than children receiving local anesthesia with the traditional syringe. Within the high-anxious group no differences were found. It was concluded that low-anxious children seem to benefit from the use of the Wand instead of the traditional syringe in receiving local anesthesia.

A conceptual model of parental behavior change following a child's dental general anesthesia procedure

PURPOSE

The purpose of this study was to investigate parents' challenges to long-term maintenance of healthy behaviors following their child's dental general anesthesia (GA).

METHODS

Twenty-six in-depth interviews were conducted with parents of children younger than 6 years of age who had dental treatment under GA. The interviews were scheduled at various time periods following the surgery. Compared were the responses of: (1) "relapse" families, whose child had new cavities at the 6-month recall; and (2) "no relapse" families, who were caries-free at recoil. A grounded theory approach to data analysis was used.

RESULTS

"Relapse" parents: (1) valued baby teeth differently; (2) perceived their child to be less susceptible to new cavities; and (3) expressed lower self-efficacy for controlling their child's oral health compared to "no relapse" parents. They also appeared to be: (1) in earlier stages of change; (2) less receptive to advice from others, including professionals; and (3) more permissive regarding their child's desires. "Relapse" parents did not seem to have any immediate plans to change their "home-care" behaviors.

CONCLUSION

GA did not appear to affect long-term preventive behaviors for all parents. Readiness to change seemed to be an important predictor of whether parents adopted and maintained preventive behaviors to improve their child's oral health.

Effects of video information on parental preoperative anxiety level and their perception of conscious sedation vs. general anesthesia for the dental treatment of their young child

AIM

To investigate the impact of video information on parental preoperative anxiety and perception and their preference of conscious sedation versus general anesthesia for the dental treatment of young patients.

METHOD/MATERIALS

Parents were given a verbal explanation regarding the two treatment options and were then asked to fill out a prescreening questionnaire. Their preference for mode of treatment was obtained and their preoperative anxiety level was measured on a visual analog scale (VAS). A video film depicting two children under going dental treatment with conscious sedation (CS) and a third child undergoing general anesthesia (GA) for dental treatment was shown to the parent. Following the viewing of the video film a post-screening questionnaire was given. Parents' post screening anxiety was measured and they were asked if their perception and preference of the two modes of treatment remained the same or changed.

RESULTS

40 parents were included and completed the trial. The prescreening anxiety level of parents was 2.79 (+/-1.05, SD) and was not significantly different than the post screening anxiety level of 2.91 (+/- .99 SD, paired t- test p=0.432). The majority of parents preferred CS to GA for the treatment of their child prior to screening of the video. Among the few who chose GA (n=5) all but one changed their choice after viewing the video to CS. However, this difference was not found to be statistically significant due to the small number of subjects in this group (McNemar test, p = 0.125). Most parents voiced the opinion that the video film contributed to their knowledge and also considered GA as having more risks than CS. An interesting finding was that a statistically significant difference was found regarding parent's perception of the two procedures and what they actually saw in the video. The majority of parents stated that their initial perception of GA was not similar to their viewing experience, conversely, CS matched their expectations.

CONCLUSION

Parents' anxiety regarding their child's dental treatment under GA or CS is not affected by the viewing of a video film depicting either method. Parent's perception of GA is different than the actual procedure and may affect their choice of treatment.

Reaction of 5 and 6 year olds to dental injection after viewing the needle: pilot study

The aim was to evaluate the practice of hiding the needle prior to dental anesthesia administration to children. Fourteen 5 and 6 year olds received dental treatment in two sessions. The needle was shown in one session and hidden in the other. Eleven children were cooperative and 3 uncooperative irrespective of approach. The children's behavior correlated with fears expressed by the mothers. Our initial fndintgs do not support the practice of hiding the needle.

The use of popsicles after dental treatment with local anesthesia in pediatric patients

The purpose of the study was to assess how children felt after dental treatment when receiving apopsicle or a toy Each patient received either a popsicle or a toy after dental treatment on the first visit, and the other on the second visit. A significant difference (p = 0.0235) was found 10 minutes and thereafter 30 minutes after dental treatment. More children reported feeling better when they received a popsicle than when they received a toy.

A qualitative look at parents' experience of their child's dental general anaesthesia

OBJECTIVES

Caries relapse after treatment of early childhood caries (ECC) under general anaesthesia (GA) has been frequently reported. This research used a qualitative method of inquiry to explore parents' experience of their child's treatment under GA, and their perception of the impact of this treatment on their child.

METHODS

The participants were parents whose children had recently undergone dental rehabilitation under GA. Data was collected by semistructured, open-ended interviews scheduled at the postoperative appointment. Interviews were audio-taped, transcribed, checked and coded into a qualitative computer software program for analysis. Data collection and analysis were done simultaneously, and the interview guide was modified based on responses.

RESULTS

Parents were troubled that their child needed a GA and appeared aware of the complications. While some parents felt 'guilty' and struggled to accept this mode of treatment for their child, others felt 'blameless', and were convinced that the GA was 'preferable' for their child and superior to conventional treatment. Nonetheless, all parents reported some levels of anxiety during the GA; they expressed their emotions with 'fear', 'worry' and 'concern'. After the GA, improvement was reported by most parents in their child's amount of dental pain, sleeping pattern, eating habits and acceptance of parental toothbrushing. The most common changes in their child's behaviour mentioned by parents were increased toothbrushing and decreased consumption of sugary foods. Several children who had had primary teeth extracted were distressed as a result of this 'loss'.

CONCLUSION

The general anaesthetic experience was troubling in a variety of ways for both parents and children. However, an 'early' and positive outcome of the GA was a reported improvement in dental health practices. Parents were more positive about maintaining the health of primary teeth and now knew how to take care of their child's teeth. Future exploration is required to reveal if and how the GA experience will affect long-term preventive behaviours.

Assessment of a palatal approach-anterior superior alveolar (P-ASA) nerve block with the Wand in paediatric dental patients

OBJECTIVES

The purposes of the study were to compare the reaction of children while receiving local anaesthesia for anaesthetizing maxillary incisors with a computerized device Wand: a periodontal ligament injection (PDLi) and a palatal approach-anterior superior alveolar (P-ASA) nerve block compared with a conventional buccal infiltration (CBi), and to assess the efficacy of the anaesthesia and children's reaction after treatment.

METHODS

One hundred and thirty-eight children aged 24-48 months participated in this study.

RESULTS

More children reacted negatively during injection while receiving the CBi and positively during the injection with the Wand. After treatment, significantly more children scratched the upper lip and/or the nose or complained of numbness of the region after the CBi (P = 0.000).

CONCLUSIONS

Same effectiveness was achieved with the Wand and the CBi. Children displayed better behaviour during injection when they received local anaesthesia with the WanD than they did when the CBi was used. They did not scratch the upper lip/nose and/or cried after treatment when they received the PDLi and the P-ASA, whereas they did when receiving a CBi.

Comparison of drops versus spray administration of intranasal midazolam in two- and three-year-old children for dental sedation

PURPOSE

The purpose of this retrospective record review of 2- and 3-year-old dental patients receiving intranasal midazolam (INM) was to compare drops vs spray administration to behavioral outcomes observed for agent acceptance during administration and for agent efficacy during parental separation, local anesthesia injection, and delivery of restorative dentistry.

METHODS

Temperament and attachment scores based on adaptability and approachability determinants judged by the parent and interactive and Frankl behavior rating scores determined by the operator were used to compare preoperative behavioral characteristics between the 2 groups. The Ohio State Behavioral Rating Scale (OSBRS) and the Frankl behavior rating scale were used to determine intraoperative behavioral outcomes for agent acceptance and efficacy.

RESULTS

Analysis of 64 sedation records revealed that the 2 groups had similar preoperative behavioral characteristics. Improvements in the Frankl behavioral rating scores were observed during the sedation, but no statistically significant difference between the drops and spray groups was measured using the OSBRS. For the procedural event of drug administration, however, the spray group demonstrated a statistically significant reduction (P=.025) in aversive behaviors when compared to drops administration as measured by the OSBRS. This finding was observed, even though the volume of spray was greater than used in the drops group.

CONCLUSIONS

Spray administration of INM produced significantly less aversive behavior than administering drops in 2- to 3-year-old dental patients of similar behavioral characteristics. The effectiveness of the conscious sedation technique was not influenced by the method of nasal administration. This study suggested that the use of a commercially available atomizer improved patient acceptance of INM administration but did not influence agent efficacy compared to drops administration for 2- to 3-year-old dental patients in an office setting.

Dental fear of Finnish children in the light of different measures of dental fear

OBJECTIVES

The aims were: (1) to examine the construct and reliability of the modified Dental Subscale of the Children's Fear Survey Schedule (CFSS-DS) among children of different ages and (2) to compare the correlations between fear measured with the modified CFSS-DS, the "peak value for dental fear" (PV), and "fear of dental treatment in general" (GF).

METHODS

The study sample consisted of 302, 299, 314, and 297 children aged 6, 9, 12, and 15 years, respectively. Each child received a questionnaire to be filled out at home. An explorative factor analysis with varimax rotation was performed for eight items taken from the CFSS-DS and questions on fear of pain and suction used in the mouth. For further age-specific analyses, mean values were calculated for the sum of items that loaded >0.5 on each factor. The correlations between these values and PV and GF were studied.

RESULTS

The questionnaire was reliable. Two factors were revealed for each age: "treatment of dental decay" (TDD), which included fears related to invasive treatment, and "attending the dentist" (AD), which included fears related to dental visits in general. TDD explained over 50% of the variance, except among 9-year-olds. TDD mean values were higher among older children than among younger ones and correlated more strongly with PV than with GF. AD mean values were higher among younger children than among older ones and correlated more strongly with GF than with PV.

CONCLUSION

The factor structures were fairly similar but the correlations between fear measures differed among children of different ages.

Differences Between Men and Women Regarding Attitudes Toward Dental Local Anesthesia Among Junior Students at a United Kingdom Dental School

The aim of this study was to assess the attitudes of junior dental students at a United Kingdom dental school regarding the administration and receipt of a local anesthetic injection. The effect of teaching on these attitudes was also evaluated. Data were collected by questionnaire. Previous experience with local anesthesia in a dental office did not affect students' attitudes toward administration and receipt of a local anesthetic injection from a classmate. Female students were more anxious about giving and receiving local anesthetic injections than male students. Didactic teaching decreased anxiety in relation to administration and receipt of a local anesthetic injection. The results showed that male and female students in a United Kingdom dental school differed in their attitudes toward local anesthesia.

Danish dentists' knowledge, attitudes and management of procedural dental pain in children: association with demographic characteristics, structural factors, perceived stress during the administration of local analgesia and their tolerance towards pain

OBJECTIVE

The aim of the present study was to describe Danish dentists' knowledge of, attitudes towards and management of procedural pain during paediatric dental care, and to assess the importance of demographic characteristics, structural factors, perceived stress during administration of local analgesia and the dentists' own tolerance towards procedural dental pain.

DESIGN

A cross-sectional questionnaire study was conducted in Denmark in May 2001.

SUBJECTS AND METHODS

The subjects were a random sample of 30% of Danish dentists treating children. Usable information was obtained from 327 (80.3%) of the dentists in the sample.

RESULTS

One-quarter of the respondents answered that a 3-5-year-old child could report pain only with uncertainty. More than 80% of the dentists stated that they never compromised on painlessness. Very few agreed to the statement that children forget pain faster than adults. One-third agreed to, or were neutral to, the statement that all restorative care in primary teeth could be performed painlessly using N2O-O2 sedation alone. The majority of the respondents reported using three or more methods to assess the effect of their pain control methods. Almost 90% reported using local analgesia for restorative work 'always' or 'often'. A similar proportion reported using topical analgesia before injection 'always' or 'often'. Administering a mandibular block to preschool children was the procedure perceived as the most stressful (33.6%) pain control method. Demographic factors (gender), structural factors (always working alone and treating 3-5-year-old children daily), perceived stress during the administration of a mandibular block in preschool children and the dentists' own willingness to accept potentially painful dental treatment without local analgesia were associated with knowledge of, attitudes towards and management of procedural dental pain in children.

CONCLUSIONS

Danish dentists treating children demonstrate concern about procedural dental pain in children. Factors amenable to change via training and reorganization into larger clinical units seem to determine their knowledge of, attitudes towards and management of procedural dental pain in children.

Office-based ambulatory anesthesia: Factors that influence patient satisfaction or dissatisfaction with deep sedation/general anesthesia

PURPOSE

The purpose of this report was to analyze data collected in an outcomes study in an attempt to identify factors that may be significant predictors of either patient satisfaction or dissatisfaction with deep sedation/general anesthesia (DS/GA) administered in an office-based setting.

MATERIALS AND METHODS

To address the research purpose, we used a prospective cohort study design and sample of patients undergoing procedures in the office-based ambulatory setting of oral and maxillofacial surgeons practicing in the United States who received local anesthesia (LA), conscious sedation (CS), or DS/GA. The predictor variables were categorized as demographic, anesthetic technique, adverse events, and patient-oriented outcomes (satisfaction/dissatisfaction). Appropriate descriptive and exact P values were completed as indicated. Statistical significance was set at P < .05. Multivariate analyses were performed to support the interpretation of univariate findings.

RESULTS

The sample was composed of 34,191 patients, of whom 71.9% patients received DS/GA. There were 20,455 patient satisfaction forms completed, of which 14,912 forms were from patients undergoing DS/GA. Of patients who received DS/GA, 95.8% were extremely or moderately satisfied, 3.1% were neutral, and 1.1% moderately or extremely dissatisfied. Increased age and memory of postoperative instructions were identified as factors, which predicted satisfaction. The addition of nitrous oxide to some regimens also appeared to increase satisfaction. Young age, anxiety, pain, vomiting, and being awake during the procedure were predictors of dissatisfaction.

CONCLUSIONS

The findings of this study indicate that patients are overwhelmingly satisfied with DS/GA provided in an office-based ambulatory setting. Items identified as significant predictors of dissatisfaction (anxiety, pain, vomiting, being awake) generally confirm preexistent suppositions. Surprisingly, patient age (<10 years old) and memory of postoperative instructions appear to have relevance to dissatisfaction as well. Lack of specific regimens and controls prevents confirmation that nitrous oxide improves patient satisfaction rates. Although statistically significant, the variations, which resulted in a higher or lower satisfaction rate, are of questionable clinical significance in many cases.

Nitrous oxide inhalation sedation: what do patients, carers and dentists think about it?

AIM

To determine the acceptability and efficacy of nitrous oxide inhalation sedation for dental treatment to children and to compare these results with the responses of both the accompanying adult and the treating dentist.

STUDY DESIGN

A prospective, questionnaire-based survey was used.

METHODS

Fifty consecutive patients (ASA I and II) attending the Department of Paediatric Dentistry, Edinburgh Dental Institute, between 2002 and 2003 for dental treatment using nitrous oxide inhalation sedation were recruited for the study. Each patient, the accompanying adult and the dental sedationist completed a short questionnaire which sought details about the acceptability and efficacy of the sedation technique. Overall behaviour and the outcome of treatment were assessed by the dentist providing sedation using the Frankl and Houpt Behaviour Rating Scales respectively.

RESULTS

Three sets of questionnaires were completed for fifty patients (M:27; F:23), mean age 10.4 years (range: 5.3-15.8 years). Acceptance of both local analgesia and dental treatment was perceived as greater amongst patients and carers compared with treating dentists (chi2 = 11.31, P = 0.004, 2 df and chi2 = 22.52, P < 0.001, 2 df respectively). Furthermore, dentists observed that inhalation sedation helped fewer male patients with local analgesia and fewer female patients with dental treatment (chi2 = 6.83, P < 0.009, 1 df and chi2 = 3.85, p < 0.050, 1 df respectively). A greater proportion of dentists observed that patients would manage treatment without sedation and would not require sedation for future dental treatment than both patients and their accompanying carer (chi2 = 8.00, P < 0.018, 2 df and chi2 = 18.61, P < 0.001, 2 df respectively). In general, the majority of patients were co-operative and successfully completed dental treatment with inhalation sedation.

CONCLUSION

Dentists' perception of nitrous oxide inhalation sedation was generally less enthusiastic than that of patients and carers.

Attitudes to Conscious Sedation in Patients Attending an Emergency Dental Clinic

Introduction

Anxiety and fear in relation to dentistry are long-standing problems and the incidence of dental fear does not appear to be decreasing. It can result in poor dental health and wastage of clinical time. Conscious sedation is one method of allaying anxiety in dental patients and enables such patients to accept dental treatment.

Aims, Materials and Methods

A questionnaire survey was undertaken among patients attending an emergency dental clinic. Its aims were to assess the levels of dental anxiety in these subjects, the impact on their attendance for dental treatment, and their knowledge of and desire to have conscious sedation, should it be available.

Results

The results indicated that in the 72 patients who responded, levels of anxiety regarding dental treatment were high, with 49 (68%) claiming some nervousness or worse. Thirty-one (43%) cited fear/nervousness as a reason for delaying making a dental appointment. Twenty-seven (38%) were not aware of the existence of conscious sedation for dental treatment, of whom half reported that they were in the highly anxious group. Forty (56%) respondents said they would like to have sedation if it were available. Twenty-five (35%) claimed to have received sedation for dental treatment in the past.

Conclusion

It was concluded that the availability of dental sedation was currently not matching the needs and demands of several patients who took part in the survey. Increased availability of dental sedation could remove a barrier to dental care for many highly anxious dental patients.

Anxiety related to dental general anaesthesia: changes in anxiety in children and their parents

AIM

To examine the anxiety levels of children referred for dental general anaesthesia and their parents at various key points of the referral and anaesthetic procedure.

METHODS

Structured interviews and anxiety measures were conducted with 50 children attending the Department of Paediatric Dentistry, Leeds Dental Institute, and progressing to general anaesthetic (GA) and their parents. Interviews were conducted with parents and children prior to initial assessment, following assessment and prior to a GA. Anxiety was measured at each interview, using the Visual Analogue Scale for parents and the Venham's Picture test for children. A fourth telephone interview was conducted with parents one week after the GA when the degree of upset caused to parents and children by the procedure was evaluated.

RESULTS

Anxiety of children remained constant at each interview. Parent and child anxiety were not related. There was a rise in parent anxiety following initial assessment in those families attending in response to a routine referral and progressing to GA (p<0.05). There was a further rise in parent anxiety in these families immediately prior to the GA itself (p<0.001). Parent upset was strongly related to their anxiety at each of the three interviews prior to the GA (p<0.01, 0.05 and 0.001 respectively) and to the distress of their child (p<0.02). Child distress was strongly related to anxiety at each of the three interviews prior to the GA.

CONCLUSION

The anxiety levels of children did not appear to change throughout the whole GA assessment and treatment process. Parent anxiety rose significantly following assessment and again just prior to the GA. Factors contributing to parent upset post treatment were child upset and pre treatment parent anxiety levels. Children who were most anxious prior to GA found the procedure most distressing.

Parental anxiety levels during pediatric induction with and without administration of premedication for general anesthesia

This study measured parental anxiety before, during, and after elective dental procedures under general anesthesia using the Spielberger State-Trait Anxiety questionnaire. State anxiety started relatively high before the procedures, peaked immediately after induction using general anesthesia, and dropped during recovery to below the initial score. Parents, whose children were premedicated and fathers in general, had significantly higher anxiety immediately after induction. This study supports interventions to lower anxiety of the parents as well as that of children.

Allergy to local anesthetics in dentistry. Myth or reality?

BACKGROUND

Local anesthetics are drugs frequently used in dentistry. Although they are usually well-tolerated drugs, sometimes, they can cause adverse reactions of different kinds and severity. True incidence of local anesthetics' allergic reactions is unknown.

OBJECTIVES

To evaluate the incidence of immediate adverse events in subjects who required local anesthetic injection to receive dental treatment; to assess the incidence of anaphylactic allergic reactions among those recorded as adverse events; to analyze the relationship between these patients' atopic antecedents and documented allergic reactions.

MATERIAL AND METHODS

A prospective, open-label, non-comparative study including a total of 5,018 subjects who received local anesthetics during dental treatment, despite their age, was carried on in 7 either private or public odontological assistance centers. All the reactions that could appear during the first hour following the anesthetic act were assessed.

RESULTS

Twenty-five adverse reactions were diagnosed, representing 0.5% of the studied population. None of them was due to an allergic cause. Most of them (22/25) were mild, quickly reversible, psychogenic or vasovagal reactions. One of the cases was related to defects of the anesthetic technique. The remaining two cases, which were initially considered as possibly due to an allergic cause, were discarded after being studied with skin and dose provocative challenge tests with the anesthetic.

CONCLUSION

The allergic reactions to the local anesthetics are very rare and most of the adverse reactions are psychogenic/vasovagal. These facts should be known by the physician and by the dentist in order to minimize the frequent fears and "myths" about the use of local anesthetics at the dentist office.

Parental evaluation of quality of life measures following pediatric dental treatment using general anesthesia

The purpose of this study was to examine (a) parental satisfaction with the dental care their child received under general anesthesia, and (b) perception of the impact of this care on physical and social quality of life. The sample included 45 children (median age 50 months, 26 boys and 19 girls). Data were collected using a 1-page survey instrument completed by the parent at the first follow-up appointment. Dichotomous dependent variables were developed to measure parental satisfaction, dental outcome, and social impact of treatment. There was an overwhelmingly positive impression with dental outcomes (pain relief and improved masticatory efficiency). Parental perceptions in the social dimension were also positive. Parents reported more smiling, improved school performance, and increased social interaction. Relative to overall health, the majority of parents reported an improvement. Logit regression analysis revealed that absence of pain (P < .05) and increased social interaction (P < .01) had a significant impact on parents' perception of overall health. Our findings indicate that dental care under general anesthesia for preschool children has a high degree of acceptance by parents and is perceived to have a positive social impact on their child.

Patient Perceptions of Periodontal Therapy Completed in a Periodontal Practice

BACKGROUND

The perceptions that patients have of periodontal therapy have not been extensively studied and are not well understood. The purpose of this study was to assess the degree of discomfort associated with periodontal therapy carried out in a specialist practice.

METHODS

A consecutive group of 150 patients (90 females, 60 males; mean age 54.5 years) who had completed periodontal therapy, which included surgery, in a periodontal practice in Norway was studied. The patients indicated the discomfort they had experienced with periodontal therapy on a visual analog scale (VAS). Other factors associated with postoperative discomfort such as the use of analgesics were recorded.

RESULTS

The mean VAS scores were low for all procedures investigated. The highest mean score was recorded for anesthesia in the upper anterior region. There were small differences between the levels of discomfort reported by males compared to females. The VAS scores decreased with increasing age for anesthesia in the lower arch (P = 0.004) and surgery in the lower arch (P = 0.003). Virtually all (97%) of the patients perceived periodontal treatment to be associated with no more discomfort than conventional dental treatment.

CONCLUSIONS

Very low reported levels of discomfort were associated with both non-surgical and surgical periodontal therapy by Norwegian patients treated in a specialist periodontal practice.

The effects of oral conscious sedation on future behavior and anxiety in pediatric dental patients

PURPOSE

This study investigated the relationship between oral conscious sedation and subsequent behavior in the dental setting.

METHODS

The sample consisted of 38 children between the ages of 39 to 71 months (mean=50 months) who had been treated with oral sedation 2 to 34 months(mean=13 months) previously, and a control group of 38 children, matched by age (mean=51 months) and gender, who had received dental treatment without conscious sedation or general anesthesia one week to 3 years previously. Subjects were matched by age and gender. All children received a standard recall examination and a prophylaxis, during which behavior and anxiety were measured. Independent variables included age at the time of sedation, present age, gender, time elapsed since sedation, effectiveness of sedation, parental scores on Corah's Dental Anxiety Scale and parent's answers to a questionnaire. The dependent variables were child behavior (rated with the 4-point Frankl scale) and self-reported anxiety ratings.

RESULTS

Both groups had mean behavior ratings of positive or very positive (experimental group mean=3.13; control group mean=3.34). There were no statistically significant differences between the groups and there was little correlation of independent and dependent variables.

CONCLUSIONS

There is no relationship between oral conscious sedation and the future behavior of children in the dental setting.

A study of behaviour patterns of normal children in a dental situation and its relationship with socioeconomic status, family type and sibling position

Different psychosocial variables, such as socioeconomic status, family type and sibling position may be considered to be of great significance as it may influence child behaviour pattern in a dental treatment situation. 143 children in the age group of 3-14 years were selected randomly from the out patient department of Pediatric Dentistry, Dental Wing, S. C. B. Medical College, Cuttack with an aim of assessing relationship, if any, between the magnitude of behaviour and the above mentioned psychosocial variables. Behaviour rating was done using Frankl behaviour rating scale. The results of the study reveals no significant relationship between socio economic status, family type and sibling position with child behaviour pattern, but a trend has been observed that children of high socio economic back ground behave more positively, children of a nuclear family exhibit more negative attitude and middle siblings show less negative behaviour than youngest and eldest.

Clinical evaluation of the efficacy of anesthesia and patient preference using the needle-less jet syringe in pediatric dental practice

Most dentists are aware that local anesthetic injections produce the highest incidence of disruptive behavior in children. Both psychological and physiological monitoring of the response of children to dental injection, support empirical observations of clinicians. The needle-free injector delivers local anesthesia without the use of a needle. This is accomplished by delivering the anesthetic solution under high compressive forces. One hundred children between the ages of 3 to 13 years underwent operative procedures using Madajet XL. There was a statistically significant difference in favor of the instrument. The instrument was completely successful in providing anesthesia.

Dental fear among a young adult Saudian population

AIMS

To assess the prevalence of dental fear and reasons for irregular dental attendance among young adult university students; to describe the gender distribution of the dentally anxious population according to the perceived origins or sources of fear; to identify the time of fear development and preference for anaesthesia or sedation before dental treatment.

METHOD

A questionnaire incorporating the Dental Fear Scale (DFS) with items related to sources of dental fear stimuli, together with the preference of anaesthesia or sedation before dental treatment and other characteristics. Approximately 500 questionnaires were distributed among Saudian undergraduate students.

RESULTS

368 questionnaires were completed and presented for statistical analysis. The sight and sensation of anaesthetic needles and the sight, sound and sensation of the drill were rated the most fear-eliciting stimuli. Also, females tended to be more anxious than males. Increased heart rate was the most common reported physiological response to fear resulting from dental treatment. The overall level of fear of dental work among the studied population was found to be about 39%.'Lack of time' and 'no need for treatment' were found to be the main reasons for irregular dental visits. Fear of pain and trauma were the major perceived sources of reported fear reactions and were developed mainly during childhood. About 63% of the subjects preferred to have local anaesthesia before dental treatment to prevent or ameliorate dental fear.

[The possible secondary effects in cases of local anesthesia]

Local anesthetics are the safest and most effective drugs for pain control. Over 300 million local anesthetic cartridges are administered by dentists in the United States of America annually, yet serious complications reported number but a handful. Complications are categorised as localised or systemic. Localised complications arise at the site of needle penetration or anesthetic administration while systemic complications involve the entire organism. Localised complications include needle breakage, paresthesia, trismus, haematoma and facial nerve paralysis, while systemic complications are psychogenic to the act of receiving an injection, allergy and drug overdose (toxic reaction). These potential complications are briefly described in the following paper.

Children choosing between general anaesthesia or inhalation sedation for dental extractions: the effect on dental anxiety

AIM

To compare the levels of dental anxiety experienced by children having dental extractions using general anaesthesia (GA) with those having extractions using local anaesthesia and inhalation sedation (IHS) when offered a programmed choice between the two techniques prior to treatment.

DESIGN

Structured interview with child at pre-treatment and at one week (approximately) follow up.

SETTING

Community: primary health care centre.

SUBJECTS

Children aged 9-15 years referred to a local NHS Trust dental clinic (n = 88).

INTERVENTION

Child and parent provided with information about IHS and its benefits over GA for the assistance in tolerating extraction of teeth and provided with a choice of procedure.

MAIN OUTCOME MEASURE

An eight question modified child dental anxiety scale.

RESULTS

Full information was received from 76 children giving an 86% response rate. Post-operative dental anxiety was lower in children who had chosen (with their parent) IHS in comparison to those who had chosen general anaesthesia (P < 0.05). Dental anxiety remained unchanged in the group who chose to have their extractions under GA.

CONCLUSION

Children and their parents who select IHS as opposed to GA to assist in extractions demonstrate less psychological distress.

Adverse reaction to dental local anaesthetic injection--'allergy' is not the cause

OBJECTIVE

To investigate patients considered to have experienced allergic reactions to local anaesthetics administered for dental treatment.

SETTING

Dental facility within a general hospital.

PROCEDURE

Skin and intra-oral challenge tests.

RESULTS

No patients were found to be allergic to lignocaine or prilocaine. The most likely causes of the adverse reactions were found to be psychogenic.

CONCLUSION

Although allergy to lignocaine (and the other amide anaesthetic agents used in dentistry) is known to be extremely rare, it continues to be suggested as a cause when adverse reactions to dental injections occur. Psychogenic reactions are the main causes of untoward events, and some can be alarming. A smaller proportion of adverse responses can be attributed to (avoidable) intravascular injections. Adverse reactions can be reduced if injections are administered carefully.

Characteristics of children attending for dental general anaesthesia in 1993 and 1997

OBJECTIVES

To confirm clinical observations and to investigate the characteristics (demography, dental anxiety status, dental health status, treatment experiences and dental health behaviours) of children attending for dental general anaesthesia (DGA).

DESIGN

A case series design was used in which each consecutive parent and child, referred for DGA, were invited to take part.

METHOD

Identical protocols for the selection of the sample, administration of the questionnaire and clinical examination were used to ensure comparability. To account for seasonal variation the data were collected during and between the months of January and May in both 1993 and 1997. Two hundred children and their parents were selected in 1993 and 200 in 1997. The parent completed a questionnaire. It enquired of the parent and child demography, parental dental anxiety status, and the child's treatment experiences. Children were asked to complete the Children's Fear Survey Schedule (CFSS) to assess their dental anxiety. The child's caries experience was assessed using the guidelines to standardise the collection of epidemiological data throughout the UK.

RESULTS

Children studied in 1997 compared with 1993 were younger, had more decayed but fewer filled teeth, were more dentally anxious, more likely to present in pain and came from families who were in receipt of Government benefits. A linear regression analysis showed that the children with previous experience of DGA had higher levels of dental caries, fewer filled teeth, were older and attended in 1997. An individual regression for 1993 showed that an additional predictor was child attendance pattern.

CONCLUSIONS

These findings confirmed the clinical observations and suggested that children who attend in pain and present for repeated DGA represent a group of children with special dental healthcare needs. There is a need for an integrated dental healthcare service to identify such children and provide appropriate dental care facilities for them.

Dental anxiety among Israeli dental students: a 4-year longitudinal study

The aims of the present study were (a) to evaluate students' estimation of their parents' dental anxiety; (b) to measure students' dental anxiety and to study their ranking of the most fear provoking stimuli in the dental situation during their pre-clinical and clinical years; (c) to investigate gender differences among students with regard to dental anxiety. 30 3rd-year students (15 male and 15 female) who completed a 4-section questionnaire which requested sociodemographic information, evaluation of parents' dental anxiety, dental anxiety scale (DAS) and dental fear scale (DFS), completed the DAS and DFS in their 5th and 6th years. Both male and female students estimated their mothers' dental anxiety as significantly higher than their fathers'. Female students ranked their parents higher than males. DAS scores were significantly higher among female students than among males in the 3rd year. However, DAS scores were reduced from the 3rd to the 6th year among the total class and significantly among females, while males' levels of anxiety remained within close range throughout the years. The dental anxiety scores of all students who experienced a dental procedure in the past were higher than the scores of the students who did not. The most fearful stimulus was 'feeling the needle'. Our findings may suggest that the change in the reported dental anxiety of the students during the years of dental studies in the present study may be explained by the increased professional education and clinical experience that the students acquire throughout their studies in the dental school. Being exposed to basic trivial dental procedures (such as local anaesthetic injection) may help students either to be habituated or to use rational coping strategies when dealing with personal dental experience.

Comparison of a controlled injection pressure system with a conventional technique

OBJECTIVE

The purpose of this study was to compare a device that controls flow rate during injection through use of a foot pedal with a conventional atraumatic syringe injection technique. We determined the change from preinjection to postinjection anxiety, the pain perception, procedure tolerance, and anxiety about future injections.

STUDY DESIGN

Dental injection anxiety questionnaires were completed by 80 endodontic patients immediately before and after administration of local anesthetic with the 2 experimental methods. Patients also completed visual analog scales to rate their pain perception during injection, their rating of the overall experience, and their anticipated anxiety about a future dental injection.

RESULTS

Patients experienced significantly lower overall postinjection anxiety and pain of injection and had significantly more positive overall experience ratings with the conventional technique than with the controlled-rate procedure.

CONCLUSIONS

A conventional atraumatic syringe injection technique was superior to a controlled injection pressure system in pain perception and procedure tolerance and in reducing postinjection dental anxiety.