Pediatric Dental Sedation Research Articles

Sedation versus protective stabilization for dental treatment of children with caries and challenging behavior at the dentist (CHOOSE): a study protocol for a non-randomized clinical trial

BackgroundThere is a lack of evidence on the effectiveness of moderate sedation in pediatric dentistry, compared to protective stabilization, which remains routinely used in Brazil despite moral questions. This prospective non-randomized clinical trial's objective is to evaluate the effectiveness of moderate sedation, compared to the protective stabilization, in the dental care of children with dental behavior management problems.MethodsParticipants will be 152 children under seven years of age with early childhood caries (ECC) who need specialized dental treatment due to a history of challenging behavior during dental care. The interventions to be compared are moderate sedation with oral administration of ketamine and midazolam and protective stabilization. The primary endpoint will be the child's behavior during treatment assessed using the Ohio State University Behavioral Rating Scale (OSUBRS). The secondary outcomes are (A) child's – behavior according to the visual analogue scale, anxiety, pain, and physiological stress; (B) parent's – satisfaction and anxiety; (C) family and child – impact on oral health-related quality of life (OHRQoL); (D) dentist's – satisfaction and stress; (E) procedure – adverse events of the intervention and dental treatment longevity. A cost-effectiveness analysis will be performed from the perspective of the Brazilian Unified Health System (SUS).DiscussionConsidering the primary outcome, this study hypothesis is that sedated children have better behavior during dental treatment than children whose behavior was managed by protective stabilization without sedation. Additionally, at the end of 12 months, we expect to identify participants' reported outcomes and objective measures related to dental behavior in early childhood.Trial registration Clinicaltrials.gov registration NCT04119180 on October 8th, 2019. https://clinicaltrials.gov/ct2/show/NCT04119180

The State of Pediatric Dental Sedation Literature and Research: A Paucity of Evidence Based Support

The State of Pediatric Dental Sedation Literature and Research: A Paucity of Evidence Based Support

Midazolam as A Sedative Agent in Paediatric Dentistry- A Literature Review

Behaviour management forms an integral part of managing children in the day to day paediatric dentalpractice. Pharmacological behaviour management strategies serve to be an effective alternative whenthe basic behaviour management technique fails. Pharmacological management strategies involve theadministration of general anaesthesia or sedation. Recently, midazolam has gained popularity for use inconscious sedation in paediatric dentistry. Midazolam has a short half-life, which results in rapid onset andrecovery in paediatric dental patients, hence encouraging its use in paediatric dentistry

Conscious Sedation in Pediatric Dentistry: One Step forward

Conscious Sedation in Pediatric Dentistry: One Step forward

Parents' satisfaction with paediatric dental treatment under sedation: A cross-sectional study.

Patient-reported outcomes are under-investigated in the field of paediatric dental sedation. To evaluate the satisfaction of parents/guardians with their children's dental sedation, compare it to the dentist's satisfaction, and identify associated factors. This study was performed with parents/guardians of young children treated under sedation and dentists. Participants' satisfaction was measured using the visual analogue scale (0-100). Child's behaviour was classified using the Ohio State Behavioural Rating Scale. Other information was collected during interviews and from patient charts. The Spearman's, Mann-Whitney and Kruskal-Wallis tests were performed (P<.05). A total of 167 parents/guardians and ten dentists participated in the study. Protective stabilisation and atraumatic restorative treatment (ART) were used in 69.9% and 51.5% appointments, respectively. The parents/guardians (median: 91 [25-75 percentile: 75-96]) and dentists (76 [23-98]) were satisfied. Parental/guardian satisfaction was higher than dentist satisfaction (P≤.001). Parental/guardian satisfaction was positively correlated with quiet child behaviour (r=0.347, P≤.001) and was associated with the non-use of protective stabilisation (P≤.001), no previous toothache (P=.019), and the use of ART (P=.018). The participants were satisfied with treatment under sedation. Parents/guardians were more satisfied, especially, when the child had cooperative behaviour.

Characteristics of Intravenous Midazolam Sedation with Nitrous Oxide in Pediatric Dental Treatment

Midazolam is a short-acting benzodiazepine that is widely used in pediatric dental sedation. However, its clinical effectiveness as an intravenous sedative agent in children has not been widely documented. A retrospective study was conducted to evaluate the efficacy and safety of intravenous midazolam and nitrous oxide inhalation sedation in pediatric dental treatment.&lt;br/&gt;The subjects were 115 patients (118 cases) who received dental treatment under intravenous midazolam and nitrous oxide inhalation sedation. Demographic factors, general health status, sedation time, midazolam and nitrous oxide dosage, and success rate of sedation were evaluated from electronic medical records.&lt;br/&gt;Behavioral management was the main reason of choosing sedation. Mean duration of sedation was 56.7 minutes for surgical treatment, and 74.4 minutes for restorative treatment. The initial dosage of intravenous midazolam was 0.051 ± 0.019 mg/kg. In 34 cases (28.8%), additional midazolam of 0.036 ± 0.057 mg/kg was delivered during the treatment. The concentration of nitrous oxide was maintained between 40% and 50%. The success rate of sedation was 99% (n = 117). In 1 case, laryngospasm occurred and the patient was reversed with benzodiazepine antagonist, flumazenil.&lt;br/&gt;Intravenous midazolam sedation with nitrous oxide was shown to be clinically effective for the dental treatment in children, if administered by trained personnel and patients are carefully selected in accordance with guidelines.

Safety of chloral hydrate sedation in dental practice for children: an overview.

Chloral hydrate is the oldest and most common sedative drug used in moderate sedation for pediatric dental patients. Hence, the purpose of this article is to review the safety and possible adverse events of this drug when used for pediatric dental treatment. A bibliographic search in PubMed, MEDLINE, Cochrane Library and KMbase, KISS, DBpia, KoreaMed, and RISS databases was performed. Using the keywords “dental sedation,” “chloral hydrate,” and “children or adolescent,” 512 scientific articles were found. Subsequently, 183 studies were individually assessed for their suitability for inclusion in this literature review. Altogether, 24 studies were selected. They included 12 cases of death before, during, or after chloral hydrate sedation for dental treatment, majorly due to dosing error and use of multiple sedatives. Additionally, intraoperative adverse events were mostly respiratory problems such as hypoxia and apnea, but most events were temporary. After treatment, prolonged sedation, including excessive sleep and less activity were the most common postoperative adverse events, and even death cases were reported. Despite the wide acceptance of chloral hydrate as a sedative-hypnotic agent, the risk of adverse events and adequate dose should be of great concern when using it for pediatric dental sedation.

Crossover Studies of Pediatric Dental Sedation are Inappropriate.

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

Role of dexmedetomidine in pediatric dental sedation.

Dexmedetomidine is a highly selective α2-adrenoceptor agonist with a vast array of properties, making it suitable for sedation in numerous clinical scenarios. Its use was previously restricted to the sedation of intensive care unit patients. However, its use in pediatric dental sedation has been gaining momentum, owing to its high suitability when compared with conventional pediatric sedatives. Its properties range from sedation to anxiolysis to analgesia, due to its sympatholytic properties and minimal respiratory depression ability. Because dexmedetomidine is an efficacious and safe drug, it is gaining importance in pediatric sedation. Thus, the aim of this review is to highlight the properties of dexmedetomidine, its administration routes, its advantages over the commonly used pediatric sedatives, and especially its role as an alternative pediatric sedative.

Dexmedetomidine versus midazolam for conscious sedation in children undergoing dental procedures

Background Pediatric dental sedation aims to have a cooperative child who is required to keep his mouth open during the procedure. Achieving the proper level of sedation might subject the child to circulatory and ventilatory troubles, which draws the attention toward performing researches for the proper sedative to be used in such circumstances. Aim of the work This study compares the effect of two sedatives (dexmedetomidine vs. midazolam) in children undergoing dental procedures. Patients and methods A total of 60 ASA I children aged 6–10 years who were scheduled for lower jaw dental procedure were enrolled in the current study. Children were randomized into two equal groups. In group D (dexmedetomidine group, n=30), 2-µg/kg dexmedetomidine was administered intravenously over 5 min as induction dose, followed by continuous infusion of 0.4 µg/kg/h as a maintenance. In group M (midazolam group, n=30), 0.05 mg/kg midazolam was administered intravenously followed by maintenance dose of 0.06–0.12 mg/kg/h titrated according to patient response. Local infiltration anesthesia was given by the dentist as 0.5 mg/kg mepivacaine 2%. Results In this study, mean arterial blood pressure, heart rate, respiratory rate, and oxygen saturation showed no significant differences between both groups. The time of onset of sedation was comparable between both groups (4.7±1.1 vs. 4.1±1.8 min in group D and group M, respectively). However, recovery time was highly significantly shorter in group D compared with group M (14.3±1.1 vs. 20.2±9.8 min, respectively). The duration of the procedures (24.7±3.1 vs. 22.2±7.5 min in group D and group M, respectively) and discharge times (14.1±2.2 vs. 13.5±5.9 min in group D and group M, respectively) were comparable between both groups. Number of patients requiring supplemental analgesia was significantly lower in group D compared with group M (6 vs. 16, respectively). Dentist satisfaction was equivalent in both groups of the study. Conclusion Dexmedetomidine and midazolam are safe and effective for consciously sedating pediatric patients undergoing dental procedures. Dexmedetomidine shows faster recovery and better postoperative analgesia compared with midazolam.

General anesthesia and sedation in pediatric dentistry - definition, purpose, advantages and disadvantages

Общата анестезия е артифициално, контролирано състояние на липса на съзнание, придружено от загуба на защитни рефлекси, самостоятелно дишане, както и невъзможност за реакция на физически стимули и вербални команди. Седирането е минимално ниво на депресия на ЦНС на подсъзнателно ниво, при която пациентът има самостоятелно дишане и реагира на физически стимули и вербални команди; запазени са всички рефлекси. Седирането изключва загубата на съзнание. За детската дентална медицина общата анестезия е фармакологична техника на управление на поведението, мотивирана от нуждата от диагностика и лечение, осигуряваща сигурността и комфорта на денталния лекар и пациента.

Conscious sedation in pediatric dentistry

Conscious sedation in pediatric dentistry

Comparison of nitrous oxide/midazolam and nitrous oxide/promethazine for pediatric dental sedation: A randomized, cross-over, clinical trial

This study compared the safety and efficacy of nitrous oxide (N2O)/midazolam and N2O/promethazine for dental treatment of uncooperative children. In this randomized, cross-over, clinical trial investigation Eighteen healthy uncooperative children with a pair of similar teeth requiring the same treatment were included. Combination of N2O/midazolam was given in one visit, where N2O/promethazine was administrated in the other appointment for each patient in a cross-over manner. Oxygen saturation and heart rate as well as behavior parameters according to Houpt behavior scales were recorded. Postoperatively, patients' anxiety and parents' satisfaction were assessed by visual analog score and a questionnaire, respectively. Data were analyzed using Wilcoxon' s signed rank test and Paired t-tests with a P value set at 0.05. Physiologic parameters were within normal limit in both groups. Children in midazolam group were significantly deeper sedated compared to other groups. In the first phase, children sedated with midazolam behaved superiorly in comparison to promethazine, while there was no difference at the final phase of the treatment between the two groups. Both of the drug combinations resulted in acceptable, efficient, and safe sedation outcomes.

Development of a Web-Based Nationwide Korean Pediatric Dental Sedation Registry.

Finding a balance between sedation efficacy and safety remains an ongoing challenge. In children, the risk of sedation-related complications is relatively high. It is of utmost importance to determine the factors related to improved overall sedation outcomes. However, most previous reports have been based on small samples at single institutions. The Korean Academy of Pediatric Dentistry (KAPD) developed a Korean Pediatric Dental Sedation Registry using a web-based platform. Specialists in pediatric dental sedation selected the itemized list included within the registry through an extensive literature review. The web-based registry was built into the KAPD homepage to facilitate easy access to the sedation data. All teaching and university hospitals agreed to participate in the Korean Pediatric Dental Sedation Registry. This is the first attempt to collect sedation data on a nationwide scale in the field of pediatric dentistry. The sedation database established with the registry may facilitate standardizing and improving pediatric dental sedation clinical practices.

Detection of Respiratory Adverse Events in Pediatric Dental Patients Sedated With 0.75mg/Kg of Midazolam and Oxygen by Continuous Pretracheal Auscultation: A Prospective Randomized Controlled Trial.

Sedation is becoming more commonplace for pediatric patients undergoing minor procedures. Fortunately, electronic monitors have contributed to a reduction in the associated respiratory adverse events (RAEs). To test the hypothesis that adding the pretracheal stethoscope (PTS) to standard monitoring methods (SMMs) may improve RAE detection in sedated pediatric dental patients, the frequency of RAEs detected by SMMs (i.e. visual observation, capnography, and pulse oximetry) was compared to that detected by SMMs alongside continuous PTS auscultation. A prospective, randomised, controlled trial was performed with 100 pediatric patient participants of ASA≤2, who were scheduled to receive dental treatment under 0.75 mg/kg and oxygen. Patients were randomised into Groups A (n=50; SMMs) and B (n=50; SMMs+PTS). Inclusion criteria were behavioral management problems and intolerance to dental treatment despite behavioral management techniques or nitrous oxide administration. Exclusion criteria were high-risk conditions for RAEs, altered mental status, gastrointestinal disorders, parental refusal of conscious sedation and failure of previous conscious sedation. An anesthesist was present throughout the dental treatments. RAEs were detected in 10 (20%) and 22(44%) Group A and B patients respectively (p=0.01). The majority of RAEs within Group B were detected by PTS auscultation (n=19). Capnography produced 13 and 15 false-positive results in Groups A and B respectively, whereas the PTS produced 4(8%) false-positive results in Group B (p=0.009). PTS was found to be useful for detecting RAEs during pediatric dental sedation with 0.75mg/kg midazolam and oxygen, in the presence of an anesthesist.

Is pain during pediatric dental sedation associated with children’s pre-operative characteristics? An exploratory study

Abstract Introduction Little is known about the factors associated with the pain of children in dental treatment under conscious sedation. Objective To investigate the association between preoperative characteristics and pain during pediatric dental treatment under sedation. Material and method This exploratory study was conducted with 27 children in restorative treatment under sedation. Information on age, sex and experience of the children with previous dental treatment was obtained through interviews with parents. Oral health status, determined from the presence of dental caries, was verified using the dmf-t index. Pain was assessed by analyzing videos of the dental treatments by two previously calibrated examiners, using the items “legs”, “activity” and “crying” of the observational scale “face, legs, activity, consolability and crying” (FLACC). Data were analyzed using bivariate tests. Result Most of the children (n=14, 51.8%) had no pain during dental treatment under sedation. Among the other children, lower or moderate pain scores (median 1.1; minimum 0 to 3.8) were observed. The FLACC scores did not vary according to sex (P=0.38), previous experience with dental treatment (P=0.32) and history with local anesthesia (P=0.96). The FLACC scores did not correlate significantly with age (Spearman rho= -0.08, P=0.67) and dmf-t (Spearman rho= -0.04, P=0.84). Conclusion In this group of children, pain during dental treatment under sedation was of low frequency and intensity and did not associate with age, sex, oral condition and previous dental experience.

Morbidity and Mortality Involving Pediatric Dental Sedation: Non-Compliance Following Sedation Guidelines

Morbidity and Mortality Involving Pediatric Dental Sedation: Non-Compliance Following Sedation Guidelines

Relationships between Respiratory Diseases and Safety of Pediatric Dental Sedation

The safety and success of dental sedation for children depend mainly on respiratory status of patients. A special condition, that is, nasal breathing in supine position with their oral airway blocked by rubber dam, should be considered. Therefore, irrespective of medical consultation, pediatric dentists themselves should do respiratory assessment especially adenotonsillar hypertrophy, nasal obstruction, posterior nasal drainage and airway hypersensitivity. Patients with sinusitis, allergic rhinitis, asthma, snoring and OSAS(obstructive sleep apnea syndrome) can induce the sedation failure and complete management of these can improve the safety of dental sedation.

Pediatric dental sedation: challenges and opportunities.

High levels of dental caries, challenging child behavior, and parent expectations support a need for sedation in pediatric dentistry. This paper reviews modern developments in pediatric sedation with a focus on implementing techniques to enhance success and patient safety. In recent years, sedation for dental procedures has been implicated in a disproportionate number of cases that resulted in death or permanent neurologic damage. The youngest children and those with more complicated medical backgrounds appear to be at greatest risk. To reduce complications, practitioners and regulatory bodies have supported a renewed focus on health care quality and safety. Implementation of high fidelity simulation training and improvements in patient monitoring, including end-tidal carbon dioxide, are becoming recognized as a new standard for sedated patients in dental offices and health care facilities. Safe and appropriate case selection and appropriate dosing for overweight children is also paramount. Oral sedation has been the mainstay of pediatric dental sedation; however, today practitioners are administering modern drugs in new ways with high levels of success. Employing contemporary transmucosal administration devices increases patient acceptance and sedation predictability. While recently there have been many positive developments in sedation technology, it is now thought that medications used in sedation and anesthesia may have adverse effects on the developing brain. The evidence for this is not definitive, but we suggest that practitioners recognize this developing area and counsel patients accordingly. Finally, there is a clear trend of increased use of ambulatory anesthesia services for pediatric dentistry. Today, parents and practitioners have become accustomed to children receiving general anesthesia in the outpatient setting. As a result of these changes, it is possible that dental providers will abandon the practice of personally administering large amounts of sedation to patients, and focus instead on careful case selection for lighter in-office sedation techniques.

Mothers' perceptions about pediatric dental sedation as an alternative to dental general anesthesia

OBJECTIVE: Moderate sedation has limits in managing children's behavior. Existing literature lacks insight into parental perceptions about the topic. This study aimed to understand mothers' perceptions concerning sedation after their children undergone dental treatment under sedation. METHODS: Twelve mothers and one godmother of 1.3-8.4 year-old children with definitely negative behavior in the dental chair, who had dental treatment under oral sedation, were in depth interviewed according to a semi-structured guide. Responses were analysed using a thematic content method and deductive approach. Two general themes were addressed: "good facet" and "poor facet" of pediatric dental sedation. RESULTS: Analysis of interview transcripts indicated that participants perceived pediatric dental sedation according to two main analytical categories: the "good facet" and the "poor facet". The good facet included advantages of the procedure (e.g. safety, effective behavior management), rapport and completion of the treatment that was initially planned. The poor facet related to limitations of moderate sedation (when child kept struggling) and their own anxiety during the procedure. CONCLUSION: Despite their own stress, mothers were satisfied with this pharmacological method of behavior management.