Sedation of anxious children undergoing dental treatment

Conscious sedation in children: the need to strengthen the evidence base remains

Data sources Cochrane Oral Health's Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), Medline and Embase. The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and World Health Organisation International Clinical Trials Registry Platform were searched for ongoing trials. Reference lists of eligible studies were checked for additional studies and specialists in the field contacted for any unpublished data. No restrictions were placed on language or publication date.Study selection Studies were selected which met the following criteria: randomised controlled trials of conscious sedation undertaken by a dentist, anaesthetist or one of the dental team comparing two or more drugs/techniques/placebo in children (up to 16 years of age) receiving dental treatment. Crossover trials and studies involving complex surgical procedures were excluded. Data extraction and synthesis Two authors independently selected studies for inclusion, extracted data and assessed for risk of bias. Results were compared and inconsistencies noted, with disagreements resolved by discussion. Where information was unclear or incomplete the authors of trials were contacted for clarification. Results Fifty studies (3704 participants) were included and grouped into placebo-controlled, dosage and head-to-head comparisons. There was wide variation in sedation technique and agent(s) employed across studies (34 different sedatives with or without nitrous oxide). Risk of bias was high for forty studies (81%), low for one study and unclear for the remaining nine studies (18%). Meta-analysis of available data for the primary outcome measure (behaviour) was possible for oral midazolam versus placebo only. There is moderate-certainty evidence from six small clinically heterogeneous studies at high or unclear risk of bias, that oral midazolam in doses between 0.25 mg/kg to 1 mg/kg is associated with more co-operative behaviour compared to placebo. It was not possible to draw conclusions regarding secondary outcome measures (completion of treatment, postoperative anxiety, adverse events) due to inconsistent and/or inadequate reporting.Conclusions There is some moderate-certainty evidence that oral midazolam is an effective sedative for dental treatment in children. Improvements and greater consistency in the design and reporting of future research will enable further evaluation of sedation agents and their potential implications for practice; with it being suggested future trials evaluate experimental regimens in comparison with oral midazolam or inhaled nitrous oxide.

Sedation of children undergoing dental treatment

BACKGROUND

Children's fear about dental treatment may lead to behaviour management problems for the dentist, which can be a barrier to the successful dental treatment of children. Sedation can be used to relieve anxiety and manage behaviour in children undergoing dental treatment. There is a need to determine from published research which agents, dosages and regimens are effective. This is the second update of the Cochrane Review first published in 2005 and previously updated in 2012.

OBJECTIVES

To evaluate the efficacy and relative efficacy of conscious sedation agents and dosages for behaviour management in paediatric dentistry.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 22 February 2018); the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 1) in the Cochrane Library (searched 22 February 2018); MEDLINE Ovid (1946 to 22 February 2018); and Embase Ovid (1980 to 22 February 2018). The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

Studies were selected if they met the following criteria: randomised controlled trials of conscious sedation comparing two or more drugs/techniques/placebo undertaken by the dentist or one of the dental team in children up to 16 years of age. We excluded cross-over trials.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted, in duplicate, information regarding methods, participants, interventions, outcome measures and results. Where information in trial reports was unclear or incomplete authors of trials were contacted. Trials were assessed for risk of bias. Cochrane statistical guidelines were followed.

MAIN RESULTS

We included 50 studies with a total of 3704 participants. Forty studies (81%) were at high risk of bias, nine (18%) were at unclear risk of bias, with just one assessed as at low risk of bias. There were 34 different sedatives used with or without inhalational nitrous oxide. Dosages, mode of administration and time of administration varied widely. Studies were grouped into placebo-controlled, dosage and head-to-head comparisons. Meta-analysis of the available data for the primary outcome (behaviour) was possible for studies investigating oral midazolam versus placebo only. There is moderate-certainty evidence from six small clinically heterogeneous studies at high or unclear risk of bias, that the use of oral midazolam in doses between 0.25 mg/kg to 1 mg/kg is associated with more co-operative behaviour compared to placebo; standardized mean difference (SMD) favoured midazolam (SMD 1.96, 95% confidence interval (CI) 1.59 to 2.33, P < 0.0001, I2 = 90%; 6 studies; 202 participants). It was not possible to draw conclusions regarding the secondary outcomes due to inconsistent or inadequate reporting or both.

AUTHORS' CONCLUSIONS

There is some moderate-certainty evidence that oral midazolam is an effective sedative agent for children undergoing dental treatment. There is a need for further well-designed and well-reported clinical trials to evaluate other potential sedation agents. Further recommendations for future research are described and it is suggested that future trials evaluate experimental regimens in comparison with oral midazolam or inhaled nitrous oxide.

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

BACKGROUND

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

AIM

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

DESIGN

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

RESULTS

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

CONCLUSIONS

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

A systematic map of systematic reviews in pediatric dentistry--what do we really know?

Objectives

To identify, appraise and summarize existing knowledge and knowledge gaps in practice-relevant questions in pediatric dentistry.

Methods

A systematic mapping of systematic reviews was undertaken for domains considered important in daily clinical practice. The literature search covered questions in the following domains: behavior management problems/dental anxiety; caries risk assessment and caries detection including radiographic technologies; prevention and non-operative treatment of caries in primary and young permanent teeth; operative treatment of caries in primary and young permanent teeth; prevention and treatment of periodontal disease; management of tooth developmental and mineralization disturbances; prevention and treatment of oral conditions in children with chronic diseases/developmental disturbances/obesity; diagnosis, prevention and treatment of dental erosion and tooth wear; treatment of traumatic injuries in primary and young permanent teeth and cost-effectiveness of these interventions. Abstracts and full text reviews were assessed independently by two reviewers and any differences were solved by consensus. AMSTAR was used to assess the risk of bias of each included systematic review. Reviews judged as having a low or moderate risk of bias were used to formulate existing knowledge and knowledge gaps.

Results

Out of 81 systematic reviews meeting the inclusion criteria, 38 were judged to have a low or moderate risk of bias. Half of them concerned caries prevention. The quality of evidence was high for a caries-preventive effect of daily use of fluoride toothpaste and moderate for fissure sealing with resin-based materials. For the rest the quality of evidence for the effects of interventions was low or very low.

Conclusion

There is an urgent need for primary clinical research of good quality in most clinically-relevant domains in pediatric dentistry.

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

AIM

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

STUDY DESIGN

Retrospective study of clinical outcomes based on dental records.

METHODS

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

RESULTS

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

CONCLUSION

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

Factors affecting efficacy of oral trimeprazine sedation for dental procedures in children: A retrospective study

OBJECTIVE

To investigate the influence of factors such as age, gender and pre-operative behavior rating on the outcome of sedation using oral trimeprazine during dental treatment of children.

METHOD

Records of children who received dental treatment under sedation with oral trimeprazine between 2000 and 2007 were reviewed and the following data were obtained: age and weight of patient at the time of treatment, gender, behavior classification prior to sedation, dose of medication used, efficacy of sedation and treatment accomplished. Descriptive statistics, cross-tabulations and χ (2) analysis were done.

RESULT

Forty-eight sedation sessions met the inclusive criteria for children whose mean age was 4.92 (SD 1.65, range 3.0-8.0) years and mean weight was 18.23 (SD 4.82, range: 12.0-31.0) kg. Overall, 54.2% (26/48) of the sedations were rated successful, 20.8% (10/48) were partially successful and 25.0% (12/48) not successful. Younger children 3-5 years, and those with only negative pre-operative behavior rating had more successful sedation sessions than older, 6-8 years or children with definitely negative pre-operative behavior rating (X (2) = 8.165, p = .017) and (X (2) = 17.258, p = .001), respectively.

CONCLUSION

Variables such as patient's age and pre-operative behavior but not gender and type of treatment could predict outcome of dental sedation using trimeprazine in children.

Short communication: dental anxiety levels and outcomes of care: a preliminary report on experiences of a sedation assessment clinic

AIM

This was twofold: (1) to report on the type of paediatric patient referred to the sedation assessment clinic at the Glasgow Dental Hospital and School, and (2) to report on the level of anxiety.

METHODS

This was a two-part study. The first part was a retrospective review of case notes to evaluate referral pathways to and from the sedation assessment clinic with regard to a range of variables. The second part was a prospective clinical report of dental anxiety.

RESULTS

It was noted that 31 (67.4%) of patients were initially referred by their general dental practitioner, 7 (15.2%) by community dental surgeons and 8 (17.4%) by hospital dental surgeons. At the initial referral, 4 children (9%) showed symptoms of pain. The majority of patients were from lower social economic areas, as determined by DEPCAT score and exhibiting moderate to high anxiety levels. The children who were referred for general anaesthesia had the highest anxiety scores. Out of a total of 46 patients, five failed to complete treatment within the modality laid out for them at the assessment clinic.

CONCLUSIONS

(1) The patients attending the newly established sedation assessment clinic were mainly high caries risk, socially deprived patients and (2) that the majority of patients were dentally anxious, the most anxious appearing to have been referred for treatment under general anaesthesia.

Is intravenous conscious sedation for surgical orthodontics in children a viable alternative to general anaesthesia? – a case review

AIM

The aim of this case review was to describe the use of local anaesthesia (LA) and intravenous conscious sedation (IVCS) as a safe and effective means of managing patients requiring surgical orthodontic procedures as an alternative to general anaesthesia (GA) in children between the age of 11 and 15 years.

MAIN OUTCOME MEASURES

1) Whether treatment was completed, partially completed or not completed; 2) assessment of physiological parameters to verify safety profile of the technique.

METHODS

Records were reviewed retrospectively for all patients included in the series undergoing planned surgical orthodontic procedures between January 2001 and January 2004 under IVCS. All patients had been pre-assessed and deemed to be of sufficient mental and physical maturity to be treated with IVCS. Written informed consent was gained from patients and their parents/guardians with full discussion of the alternative pain and anxiety control methods available including GA. All cases were undertaken by experienced SAS grade surgeons assisted by two dental nurses holding the certificate in dental sedation nursing and their recovery was supervised by registered general nurses. Patients were clinically monitored throughout together with continuous pulse oximetry and intermittent recording of non invasive blood pressure and pulse at 10-15 minute intervals. Patients were reviewed post operatively and any complications or comments noted.

RESULTS

Over a three year period a total of 107 patients underwent surgical procedures to aid orthodontic treatment, 28 (26%) under IVCS and 79 (74%) under GA. Twenty-five out of 28 patients in the IVCS group successfully completed all of their planned treatment.

CONCLUSIONS

Based on this case series, IVCS would appear to offer a safe and effective alternative to GA for this group of patients providing they are selected and managed by an appropriately trained team in a suitable setting. Further prospective evidence is needed if IVCS is to be recommended for general dental treatment in patients under the age of 16 years.