An RCT pilot study to test the effects of intravenous midazolam as a conscious sedation technique for anxious children requiring dental treatment--an alternative to general anaesthesia

Quality of dental treatments under intravenous sedation among patients with disability: A self-matching study

Background/purpose

Patients with disabilities usually have difficulties in communication and mobility, and the quality of the dental treatments are often inferior. This study uses the Taiwan National Health Insurance Database to analyze the quality of dental treatment for patients with disabilities who receive intravenous sedation (IVS).

Materials and methods

This study selected patients with disabilities who received dental treatment under IVS. Their oral cavity was divided into three major sections: anterior teeth, upper posterior teeth, and lower posterior teeth. Self-matching of the same section was conducted to observe whether operative dental treatment (OD) with or without IVS affected the occurrence of dental retreatment. This study observed the occurrence of refilling and the duration from the end of treatment until retreatment to compare treatment differences with or without IVS.

Results

After self-matching, this study found 158 patients who received dental treatment within the same section with and without IVS. During a follow-up period of 17 years, 75.18% of the patients who received OD treatment required refilling, 10.87% required endodontic treatment, and 5.67% required tooth extraction. After OD treatment with IVS, the risks of refilling, endodontic treatment, and tooth extraction were 0.71 (95% CI: 0.58-0.87, P < 0.001), 0.77 (95% CI: 0.48-1.23, P = 0.28), and 0.64 (95% CI: 0.32-1.27, P = 0.20), respectively.

Conclusion

For patients with disabilities, OD treatment with IVS significantly reduces the risk of refilling compared with OD treatment without IVS. IVS can be ideal for people with disabilities who receive dental treatment.

Comparative Assessment of Anxiety during Inferior Alveolar Nerve Block under Nitrous Oxide + Oxygen and Oxygen Inhalation Sedation in Children Aged 3-12 Years: A Randomized Clinical Trial

Aim

A comparative evaluation of children's anxiety with the use of nitrous oxide-oxygen (N2O-O2) inhalation sedation during the administration of inferior alveolar nerve block (IANB).

Materials and methodology

A total of 60 children between 3 and 12 years of age, with Frankl's behavior rating of 2-3 requiring IANB for any dental procedure were enrolled in this randomized clinical study. Group I (n = 30) received N2O and oxygen inhalation sedation at a concentration in the range of 25-50%, whereas group II (n = 30) received 100% O2 as a placebo. The physiological parameters like pulse rate, respiration, blood pressure, and O2 saturation were measured at the baseline, intraoperatively [during and after administration of local anesthesia (LA)] and postoperatively after the termination of the gases in both groups. The sedation level was measured intraoperatively (before administration of LA) using the Ramsay Sedation Score (RSS). The discomfort and anxiety were measured at the baseline, intraoperatively, and postoperatively using the Face, Legs, Activity, Cry, Consolability (FLACC) behavior scale. The data were evaluated using the statistical software International Business Machines (IBM) Statistical Package for the Social Sciences (SPSS) statistics 20.0.

Results

There was a significant difference in the FLACC scores between the two groups, intraoperatively (p-value-0.002), and postoperatively (p-value-0.049). The mean of the RSS for group I was 2.80 + 1.03, and for group II was 1.80 + 0.81. All the physiological parameters recorded were within the normal range.

Conclusion

The use of N2O-O2 inhalation improved the anxiety levels in children while receiving the IANB and showed significant anxiolytic and sedative effects as compared to O2 inhalation.

Clinical significance

Nitrous oxide-oxygen (N2O-O2) inhalation can be used as a nonpharmacological behavior management adjunct for invasive treatments for children with utmost comfort for the child.

How to cite this article

Thomas PS, Dave BH, Shah DJ, et al. Comparative Assessment of Anxiety during Inferior Alveolar Nerve Block under Nitrous Oxide + Oxygen and Oxygen Inhalation Sedation in Children Aged 3-12 Years: A Randomized Clinical Trial. Int J Clin Pediatr Dent 2023;16(1):30-36.

Effects of Low-Concentration Nitrous Oxide Anesthesia on Patient Anxiety During Cataract Surgery: A Retrospective Cohort Study

Purpose

We investigated the effects of 30% low-concentration nitrous oxide (N₂O) anesthesia on anxiety, pain, and vital signs and the patient population that would benefit from low-concentration N₂O anesthesia during cataract surgery.

Patients and Methods

Sixty-three patients who underwent cataract surgery due to visual impairment from cataracts were included in this single-center retrospective cohort study conducted at the Ophthalmology Department of Shinseikai Toyama Hospital, Japan. Fifty eyes of 39 patients received a combination of local and N₂O anesthesia (N₂O group), and 30 eyes of 24 patients received local anesthesia without N₂O anesthesia (Air group). The primary outcome measures were visual analogue scale (VAS) scores for patient anxiety, pain, and vital signs. The secondary outcome measures were the patient population.

Results

The change in the VAS scores for anxiety and pain decreased significantly (p = 0.002 and p = 0.014, respectively) in the N₂O group (−15.6 ± 22.9 and 12.4 ± 14.9, respectively) compared with that in the Air group (1.2 ± 20.6 and 24.2 ± 22.4, respectively). The systolic and diastolic blood pressure changes did not significantly differ between both groups (p = 0.093 and p = 0.23, respectively). The change in heart rate decreased significantly (p = 0.001) in the N₂O group (−4.8 ± 4.8 bpm) compared with that in the Air group (−0.6 ± 5.8 bpm). Multivariate analyses demonstrated that the change in anxiety level in the N₂O group correlated significantly with patient age (p = 0.045) and preoperative VAS score for anxiety (p = 0.0001), whereas the change in anxiety level in the Air group did not correlate with any factor.

Conclusion

Low-concentration N₂O anesthesia showed beneficial effects on intraoperative anxiety and pain during cataract surgery; this may aid the stabilization of intraoperative vital signs. Moreover, low-concentration N₂O anesthesia during cataract surgery could benefit young patients and patients with high levels of preoperative anxiety.

Evaluation of Intranasal Midazolam for Pediatric Sedation during the Suturing of Traumatic Lacerations: A Systematic Review

Objective: The objective of this study was to evaluate the efficacy and safety of intranasal midazolam as part of a paediatric sedation and analgesic procedure during the suturing of traumatic lacerations in paediatric emergency departments. Methodology: A systematic review of clinical trials was completed in July 2021. The databases consulted were PUBMED, SCOPUS, WEB OF SCIENCE, NICE and Virtual Health Library. Eligibility criteria: randomised and nonrandomised clinical trials. Two independent, blinded reviewers performed the selection and data extraction. The participants were 746 children, of whom, 377 received intranasal midazolam. All of the children were admitted to an emergency department for traumatic lacerations that required suturing. The quality of the articles was evaluated with the Jadad scale. This systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Results: Nine studies were included in the review. The intranasal administration of midazolam in healthy children produces anxiolysis and minimal/moderate sedation without serious side effects. Although there are combinations of parenteral drugs that produce deeper sedation, they also have greater adverse effects. No significant differences in the initiation of sedation and the suture procedure were found between the intranasal route and the parenteral route. Conclusions: The use of intranasal midazolam in healthy children produces sufficiently intense and long-lasting sedation to allow for the suturing of traumatic lacerations that do not present other complications; therefore, this drug can be used effectively in paediatric emergency departments.

Retrospective audit of midazolam dose and intravenous sedation record keeping in a primary care oral surgery service

Regular and robust audit of conscious sedation practice is key to the delivery of safe and effective patient care in all clinical settings. Analysis of outcomes will help to highlight any necessary modifications to procedures and techniques. The Intercollegiate Advisory Committee for Sedation in Dentistry (IACSD) states that conscious sedation procedures must be the subject of robust and regular audit in which every member within the team takes part.¹ This completed audit cycle highlighted the efficacy of intravenous (IV) midazolam in anxious patients undergoing oral surgical procedures and the suitability for its use in the primary care setting. No patient safety concerns or complications were recorded in this audit and midazolam was administered within the recommended dose range. By the conclusion of two audit cycles, all clinicians providing intravenous sedation within the service were aware of the missing elements in sedation record-keeping and were able to complete accurate contemporaneous records before, during and after conscious sedation, ensuring the continuous delivery of high-quality, safe, and patient-centred care.

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.

Complications associated with intravenous midazolam and fentanyl sedation in patients undergoing minor oral surgery

Background

Anxiety control remains an important concern in dental practice. We evaluated the incidence, nature, and sequelae of complications during and after minor oral surgeries performed under intravenous midazolam and fentanyl sedation using the titration technique.

Methods

The medical records of patients who had undergone minor oral surgeries under moderate intravenous midazolam and fentanyl sedation at our institution between January 1, 2015 and December 31, 2015 were retrospectively evaluated. Age, sex, body mass index, medical history, American Society of Anesthesiologists (ASA) classification, indications for sedation, amount of sedative used, surgical duration, and recovery time were evaluated for all patients.

Results

In total, 107 patients aged 9–84 years were included. ASA class I and class II were observed for 56.1% and 43.9% patients, respectively. Complications associated with sedation occurred in 11 (10.2%) patients. There were no serious adverse events. Oxygen saturation reached 95% during the procedure in six patients; this was successfully managed by stimulating the patients to take a deep breath. Two patients exhibited deep sedation and one exhibited paradoxical excitement. After the procedure, one patient experienced nausea without vomiting and one exhibited a prolonged recovery time. The surgical procedures were completed in all patients. Obesity was found to be significantly associated with sedation-related complications.

Conclusions

Our results suggest that complications associated with intravenous midazolam and fentanyl sedation using the titration technique for minor oral surgeries are mostly minor and can be successfully managed with no prolonged sequelae.

Inhalation Conscious Sedation with Nitrous Oxide and Oxygen as Alternative to General Anesthesia in Precooperative, Fearful, and Disabled Pediatric Dental Patients: A Large Survey on 688 Working Sessions

Aim. To evaluate the effectiveness and the tolerability of the nitrous oxide sedation for dental treatment on a large pediatric sample constituting precooperative, fearful, and disabled patients. Methods. 472 noncooperating patients (aged 4 to 17) were treated under conscious sedation. The following data were calculated: average age; gender distribution; success/failure; adverse effects; number of treatments; kind of dental procedure undertaken; number of dental procedures for each working session; number of working sessions for each patient; differences between males and females and between healthy and disabled patients in relation to success; success in relation to age; and level of cooperation using Venham score. Results. 688 conscious sedations were carried out. The success was 86.3%. Adverse effects occurred in 2.5%. 1317 dental procedures were performed. In relation to the success, there was a statistically significant difference between healthy and disabled patients. Sex and age were not significant factors for the success. Venham score was higher at the first contact with the dentist than during the treatment. Conclusions. Inhalation conscious sedation represented an effective and safe method to obtain cooperation, even in very young patients, and it could reduce the number of pediatric patients referred to hospitals for general anesthesia.

Sedation versus general anaesthesia for provision of dental treatment to patients younger than 18 years

BACKGROUND

A significant proportion of children have caries requiring restorations or extractions, and some of these children will not accept this treatment under local anaesthetic. Historically this has been managed by the use of a general anaesthetic in children; however, use of sedation may lead to reduced morbidity and cost. The aim of this review was to compare the efficiency of sedation versus general anaesthesia (GA) for provision of dental treatment to children and adolescents younger than 18 years. This review was originally published in 2009 and was updated in 2012 and again in 2015.

OBJECTIVES

We will evaluate morbidity and effectiveness of sedation versus GA for provision of dental treatment to patients younger than 18 years. If data become available, we will analyse the cost-effectiveness of different interventions. If data are not available, we will obtain crude estimates of cost.Morbidity can be defined as 'an undesired result or complication'. For the purposes of this review, 'postoperative morbidity' refers to undesired results or complications such as nausea following a procedure, once the patient had been restored to consciousness and could breathe unaided. 'Intraoperative morbidity' refers to any complications that occur during the procedure that may necessitate action by the anaesthetist or the sedationist, such as respiratory arrest.

SEARCH METHODS

In this updated review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 7); MEDLINE Ovid SP (1950 to July 2015); EMBASE Ovid SP (1974 to July 2015); System for Information on Grey Literature in Europe (SIGLE) (1980 to October July 2012); Latin American & Caribbean Health Sciences Literature (LILACS) (1982 to July 2015); and Institute for Scientific Information (ISI) Web of Science (1945 to July 2015).We also carried out handsearching of relevant journals to July 2015. We imposed no language restriction.

SELECTION CRITERIA

We planned to include randomized controlled clinical trials that compared sedative agents versus general anaesthesia in children and adolescents up to 18 years of age undergoing dental treatment. We excluded complex surgical procedures and pseudo-randomized trials.

DATA COLLECTION AND ANALYSIS

Two review authors assessed titles and abstracts for inclusion in the review. We recorded information relevant to objectives and outcome measures by using a specially designed 'data extraction form'. We will employ the Grades of Recommendation, Assessment, Development and Evaluation Working Group (GRADE) approach to interpret findings.

MAIN RESULTS

In our original review, we identified 16 studies for potential inclusion after searching available databases and screening titles and abstracts. After retrieving full-text studies, we found none to be eligible. We identified no additional studies in the updated search of July 2012. We identified two studies for possible inclusion in the updated search of July 2015; again we found these to be ineligible.

AUTHORS' CONCLUSIONS

Randomized controlled studies comparing use of dental general anaesthesia versus sedation are needed to quantify differences such as morbidity and cost.

A comparison of the sedative effect of oral versus nasal midazolam combined with nitrous oxide in uncooperative children

AIM

To compare a combination of oral midazolam (0.2 mg/kg body weight) and nitrous oxide-oxygen sedation with a combination of intranasal midazolam (0.1 mg/kg body weight) and nitrous oxide-oxygen sedation for effectiveness, patient acceptability and safety profile in controlling the behaviour of uncooperative children.

METHODS

Thirty children, 4-10 years of age, referred for dental treatment were included in the study with a crossover design. Each patient was sedated with a combination of either oral midazolam and nitrous oxide-oxygen sedation or intranasal midazolam and nitrous oxide-oxygen sedation at subsequent dental treatment visits. During the treatment procedure, the study recorded scales for drug acceptability, onset of sedation, acceptance of nasal mask, sedation, behavioural, safety, overall behaviour and alertness.

RESULTS

The grade of acceptability of midazolam in both groups was consistently good. There was a significant difference (p < 0.001) in the time of onset of sedation, which was significantly quicker with the intranasal administration of midazolam. The mean time of onset for oral midazolam was 20.1 (17-25) min and for intranasal midazolam 12.1 (8-18) min. The efficacy profile of the present study included: acceptance of nasal mask, sedation score, crying levels, motor movements and overall behaviour scores. The results did not show any statistically significant differences. All the parameters were highly satisfactory. The difference in alertness was statistically significant (p value <0.05), being higher in the intranasal group than the oral group and suggestive of faster recovery using intranasal midazolam.

CONCLUSION

The intranasal route of midazolam administration has a quick onset of action and a quick recovery of the patient from sedation as compared to the oral route of midazolam administration. Midazolam administered through the intranasal route is as effective as the oral route at a lower dosage. Therefore, it is an effective alternative to oral route for a paediatric dental situation.

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.

Sedation versus general anaesthesia for provision of dental treatment in under 18 year olds

BACKGROUND

A significant proportion of children have caries requiring restorations or extractions, and some of these children will not accept this treatment under local anaesthetic. Historically this has been managed in children by the use of a general anaesthetic, however use of sedation may lead to reduced morbidity and cost. The aim of this review is to compare the efficiency of sedation versus general anaesthesia for the provision of dental treatment for children and adolescents aged under 18 years.This review was originally published in 2009 and updated in 2012.

OBJECTIVES

We evaluated the intra- and postoperative morbidity, effectiveness and cost effectiveness of sedation versus general anaesthesia for the provision of dental treatment for under 18 year olds.

SEARCH METHODS

In this updated review we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 7); MEDLINE (Ovid) (1950 to July 2012); EMBASE (Ovid) (1974 to July 2012); System for information on Grey Literature in Europe (SIGLE) (1980 to October 2008), Latin American & Caribbean Health Sciences Literature (LILACS) (1982 to July 2012), and ISI Web of Science (1945 to October 2008). The searches were updated to July 2012. The original search was performed in October 2008.We also carried out handsearching of relevant journals to July 2012. We imposed no language restriction.

SELECTION CRITERIA

We planned to include randomized controlled clinical trials of sedative agents compared to general anaesthesia in children and adolescents aged up to 18 years having dental treatment. We excluded complex surgical procedures and pseudo-randomized trials.

DATA COLLECTION AND ANALYSIS

Two authors assessed titles and abstracts for inclusion in the review. We recorded information relevant to the objectives and outcome measures in a specially designed 'data extraction form'.

MAIN RESULTS

We identified 15 studies for potential inclusion after searching the available databases and screening the titles and abstracts. We identified a further study through personal contacts. Following full text retrieval of the studies, we found none to be eligible for inclusion in this review.

AUTHORS' CONCLUSIONS

Randomized controlled studies are required comparing the use of dental general anaesthesia with sedation to quantify differences such as morbidity and cost.

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.

OBJECTIVES

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

SEARCH METHODS

Electronic searches of MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Dissertation Abstracts, SIGLE, the World Wide Web (Google) and the Community of Science Database were conducted for relevant trials and references up to 4th August 2011. Reference lists from relevant articles were scanned and the authors contacted to identify trials and obtain additional information. There were no language restrictions. Trials pre-1966 were not searched.

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. Crossover trials were excluded.

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

Thirty-six studies were included with a total of 2810 participants. Thirty trials (83%) were at high risk of bias and six (17%) were at unclear risk of bias. There were 28 different sedatives used with or without inhalational nitrous oxide. Dosages, mode of administration and time of administration varied widely. Trials were grouped into placebo-controlled, dosage and head-to-head comparisons. Meta-analysis of the available data was possible for studies investigating oral midazolam vs placebo only. There is weak evidence from five small clinically heterogeneous trials at high risk of bias, that the use of oral midazolam in doses between 0.25 mg/kg to 0.75 mg/kg is associated with more co-operative behaviour compared to placebo; standardised mean difference (SMD) favoured midazolam (SMD 2.98, 95% confidence interval (CI) 1.58 to 4.37, P < 0.001, I² = 91%), which translates to an increase of approximately 1.8 points on the six-point Houpt behaviour scale. There is very weak evidence from two trials which could not be pooled that inhalational nitrous oxide is more effective than placebo.

AUTHORS' CONCLUSIONS

There is some weak evidence that oral midazolam is an effective sedative agent for children undergoing dental treatment. There is very weak evidence that nitrous oxide inhalation may also be effective. 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.

Complications Associated with Intravenous Midazolam Sedation in Anxious Dental Patients

Aim

This prospective study was designed to establish the nature, frequency and sequelae of complications arising in patients receiving dental treatment under intravenous midazolam sedation.

Methods

All patients attending the Sedation Department at Newcastle Dental Hospital for intravenous sedation over a six-month period were audited. A standardised data-collection pro forma was designed in order to collect data relating to the patient, the sedation episode, the dental treatment and any complications arising. The published standard used in this study states that the incidence of complications should be no more than 8%.

Results

Four hundred and one patients were included. The mean dose of midazolam administered was 7.6 mg with a mean titration rate of 0.9 mg/min. Complications were reported in 12 patients (3%), 11 of which were minor and one moderate. All complications were managed successfully within the department with no lasting sequelae. Treatment was completed in 382 (95.7%) patients, with failure to complete treatment in 17 (4.3%) patients due to disinhibition (1), poor cooperation (10), and the sedation wearing off (6).

Conclusion

The standard was met because complications arising were infrequent (3%) and predominantly minor in nature. Complications were managed conservatively and effectively, with all patients being discharged home the same day with no lasting sequelae. The study demonstrates that intravenous midazolam provides a safe sedation technique, suitable for adult dental patients in primary care, when administered by trained personnel on carefully selected patients and in accordance with nationally agreed protocols and guidelines.

Sedation versus general anaesthesia for provision of dental treatment in under 18 year olds

BACKGROUND

A significant proportion of children have caries requiring restorations or extractions, and some of these children will not accept this treatment under local anaesthetic. Historically this has been managed in children by use of a general anaesthetic; however use of sedation may lead to reduced morbidity and cost. The aim of this review is to compare the efficiency of sedation versus general anaesthesia for the provision of dental treatment for children and adolescents under 18 years.

OBJECTIVES

We evaluated the intra- and post-operative morbidity, effectiveness and cost effectiveness of sedation versus general anaesthesia for the provision of dental treatment for under 18 year olds.

SEARCH STRATEGY

We searched The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library; Issue 4, 2008); MEDLINE (OVID) (1950 to October Week 2, 2008); EMBASE (OVID) (1974 to Week 42, 2008); System for information on Grey Literature in Europe (SIGLE) (1980 to October 2008), Latin American & Caribbean Health Sciences Literature (LILACS) (1982 to October 2008), ISI Web of Science (1945 to October 2008).We also carried out handsearching of relevant journals. There was no language restriction.

SELECTION CRITERIA

We included randomized controlled clinical trials of sedative agents compared to general anaesthesia in children and adolescents aged up to 18 years having dental treatment. We excluded complex surgical procedures and pseudo-randomized trials.

DATA COLLECTION AND ANALYSIS

Two authors assessed titles and abstracts for inclusion in the review. We recorded information relevant to the objectives and outcome measures into a specially designed 'data extraction form'.

MAIN RESULTS

We identified 15 studies for potential inclusion after searching the available databases and screening the titles and abstracts. We identified a further study through personal contacts. Following full text retrieval of the studies, we found none to be eligible

AUTHORS' CONCLUSIONS

Randomized controlled studies comparing the use of dental general anaesthesia with sedation to quantify differences such as morbidity and cost are required.

Depression and anxiety in children at the end of life

A significant component of palliative care is the prompt diagnosis and management of distress, anxiety, and depression. This article reviews the symptoms and treatment of anxiety and depressive disorders in children at the end of life. Distinguishing between symptoms and disorders, the importance of open communication, consideration of the child's understanding of death, diagnostic challenges in chronically ill children, and suicidality are discussed. Because treatment options are available, it is imperative that symptoms are recognized and addressed. Understanding the issues involved in screening and diagnosis and the risks and benefits of available treatments can lead to an informed approach to the management of these disorders in the palliative care setting.

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.

What is the evidence for paediatric dental sedation?

BACKGROUND AND RATIONALE

Sedation can be used to relieve anxiety and manage behaviour in children, unfortunately it is difficult to determine from published research which agents, dosages and techniques are effective.

OBJECTIVE

To evaluate the relative efficacy of the various conscious sedation techniques and dosages for behaviour management in paediatric dentistry. DESIGN AND KEY METHODS: Relevant databases and reference lists from articles were searched up to December 2005. 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 anxious children up to 16 years of age.

RESULTS

Sixty-five studies were included with 3372 subjects in total. Overall quality of studies was found to be disappointing with poor reporting often the main problem.

CONCLUSIONS

Authors were not able to reach any definitive conclusion on which was the most effective drug or method of sedation used for anxious children due to issues with the quality and validity of published studies to date.

Sedation of anxious children undergoing dental treatment

BACKGROUND

Anxiety about dental treatment or behaviour management problems can be a barrier to its uptake in children. Sedation can be used to relieve anxiety and manage behaviour, unfortunately it is difficult to determine from published research which agents, dosages and techniques are effective.

OBJECTIVES

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

SEARCH STRATEGY

Computerised: MEDLINE, PubMed, EMBASE, Cochrane Central Register of Controlled Trials, Dissertation Abstracts, SIGLE, the World Wide Web (Google) and the Community of Science Database were searched for relevant trials and references up to December 2004. Reference lists from relevant articles were scanned and the authors contacted to identify trials and obtain additional information. There were no language restrictions. Trials pre-1966 were not searched.

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 anxious children up to 16 years of age.

DATA COLLECTION AND ANALYSIS

Information regarding methods, participants, interventions and outcome measures and results were independently extracted, in duplicate, by two authors. Authors of trials were contacted for details of randomisation and withdrawals and a quality assessment was carried out not using any formal scoring system. The Cochrane Oral Health Group statistical guidelines were followed.

MAIN RESULTS

Sixty-one studies were included with 3246 subjects in total. Overall quality of studies was found to be disappointing with poor reporting often the main problem. Data reported could not be easily aggregated into groups to facilitate description of results. Meta-analysis of the available data was also not possible for the same reason. The variety of differing drug regimens compared made it difficult to isolate groups of studies that were sufficiently similar in design to allow sensible comparison. Where groups of studies could be isolated, then the differing outcome measures used made their meta-analysis impossible.

AUTHORS' CONCLUSIONS

Review authors were not able to reach any definitive conclusion on which was the most effective drug or method of sedation used for anxious children. A list of proposed areas of study was described.

A randomised controlled trial of paediatric conscious sedation for dental treatment using intravenous midazolam combined with inhaled nitrous oxide or nitrous oxide/sevoflurane

Failure of dental treatment due to anxiety is a common problem in children. The aim of this study was to establish whether the use of a combination of intravenous midazolam with inhalation agents (nitrous oxide alone or in combination with sevoflurane) was any more likely to result in successful completion of treatment than midazolam alone. A further aim was to evaluate the clinical viability of these techniques as an alternative to general anaesthesia. In total, 697 children too anxious for management with relative analgesia and requiring invasive dental procedure for which a general anaesthetic would usually be required, were recruited and randomly assigned to one of three groups given the following interventions: group 1 - a combination of inhaled medical air and titrated intravenous midazolam, group 2 - a combination of inhaled 40% nitrous oxide in oxygen and titrated intravenous midazolam, and group 3 - a combination of an inhaled mixture of sevoflurane 0.3% and nitrous oxide 40% in oxygen with titrated intravenous midazolam. The primary outcome measure was successful completion of the intended dental treatment with a co-operative child responsive to verbal commands. In group 1, 54% (94/174 children) successfully completed treatment. In group 2, 80% (204/256 children) and in group 3, 93% (249/267 children) completed treatment. This difference was significant at the 1% level. Intravenous midazolam, especially in combination with inhaled nitrous oxide or sevoflurane and nitrous oxide, are effective techniques, with the combination of midazolam and sevoflurane the one most likely to result in successful treatment.