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

Comparison of the effects of target-controlled infusion-remifentanil/midazolam and manual fentanyl/midazolam administration on patient parameters in dental procedures

Background

Moderate sedation is an integral part of dental care delivery. Target-controlled infusion (TCI) has the potential to improve patient safety and outcome. We compared the effects of using TCI to administer remifentanil/manual bolus midazolam with manual bolus fentanyl/midazolam administration on patient safety parameters, drug administration times, and patient recovery times.

Methods

In this retrospective chart review, records of patients who underwent moderate intravenous sedation over 12 months in a private dental clinic were assessed. Patient indicators (pre-, intra-, and post-procedure noninvasive systolic and diastolic blood pressure, respiration, and heart rate) were compared using independent t-test analysis. Patient recovery time, procedure length, and midazolam dosage required were also compared between the two groups.

Results

Eighty-five patient charts were included in the final analysis: 47 received TCI-remifentanil/midazolam sedation, and 38 received manual fentanyl/midazolam sedation. Among the physiological parameters, diastolic blood pressure showed slightly higher changes in the fentanyl group (P = 0.049), respiratory rate changes showed higher changes in the fentanyl group (P = 0.032), and the average EtCO₂ was slightly higher in the remifentanil group (P = 0.041). There was no significant difference in the minimum SpO₂ levels and average procedure length between the fentanyl and remifentanil TCI pump groups (P > 0.05). However, a significant difference was observed in the time required for discharge from the chair (P = 0.048), indicating that patients who received remifentanil required less time for discharge from the chair than those who received fentanyl. The dosage of midazolam used in the fentanyl group was 0.487 mg more than that in the remifentanil group; however, the difference was not significant (P > 0.05).

Conclusion

The combination of TCI administered remifentanil combined with manual administered midazolam has the potential to shorten the recovery time and reduce respiration rate changes when compared to manual administration of fentanyl/midazolam. This is possibly due to either the lower midazolam dosage required with TCI remifentanil administration or achieving a stable, steady-state low dose remifentanil concentration for the duration of the procedure.

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.

Nitrous Oxide and Midazolam Sedation: A Systematic Review and Meta-Analysis

Nitrous oxide and midazolam have been used as sedative agents to decrease fear and anxiety associated with dental procedures. Although these agents have been widely used individually, the combination of the two is also commonly used. Four clinical trials were identified that compared the combination technique with the individual use of the drugs. The standardized mean difference (SMD) for each outcome measure was considered for final analysis. Three studies with 534 participants were included in the final meta-analysis, and the SMD [95% CI] was obtained as -0.15 [-0.32, 0.03] and was not statistically significant for cooperation scores. Two studies reported the dose of midazolam required for inducing sedation in 450 participants, and the pooled estimate of SMD [95% CI] was obtained as -0.29 [-0.48, -0.10] and was significant. Two studies with 450 participants reported the time taken to recover from sedation, and the pooled estimate of SMD [95% CI] was obtained as -0.20 [-0.39, -0.01] and favored the combination technique. To conclude, the combination technique combines the pros and cons of both drugs in causing fewer adverse effects due to midazolam by reducing the total dose and also helps to provide better acceptance of nitrous oxide inhalation.

Can intravenous conscious sedation with midazolam be effective at facilitating surgical dentistry in adolescent orthodontic patients? A service evaluation

Background Surgical dentistry during orthodontic care often occurs in adolescence and may involve surgical removal or exposure of teeth. The invasive nature of treatment, combined with dental anxiety, means care can often be provided under general anaesthesia (GA). Best-practice guidelines however endorse conscious sedation as an alternative, where appropriate. Although a limited number of studies have shown safe and effective use of intravenous conscious sedation (IVCS) with midazolam in this cohort, robust evidence to support routine use is lacking. Aim To assess whether IVCS with midazolam can effectively facilitate surgical dentistry in adolescent orthodontic patients in primary care.Method A retrospective service evaluation was undertaken reviewing clinical records of adolescents (aged 12-15 years) undergoing surgical exposure and/or surgical removal of teeth under IVCS with midazolam.Results A total of 174 adolescents (mean age 14.2 years) attended for treatment between 2009 and 2015. Of these adolescents, 98.9% (N = 172) allowed cannulation, with all surgical dentistry completed during a single visit. Midazolam dose ranged from 2-7 mg with 79.1% of patients having good or excellent cooperation and three minor adverse events occurring.Conclusion This service evaluation shows IVCS with midazolam can effectively facilitate surgical orthodontics in carefully selected adolescents. There is however a distinct need to further explore potential for this technique to provide a viable alternative to GA.

Conscious Sedation in Dentistry

Sedation in dentistry has been a controversial topic due to questions being raised over its safety, especially in dental chair. Dental fear and anxiety are not only common in children but also significantly prevalent among adults due to high intensity of pain. Sharing of airway between the anesthesiologist and the dentist remains the greatest challenge. The purpose of this review is to study the recent trends in conscious sedation in the field of dentistry from an anesthesiologist's perspective. It will provide a practical outline of the pharmacokinetics, pharmacodynamics, and routes of administration of the drugs or gases used.

Conscious Sedation: Emerging Trends in Pediatric Dentistry

Dental fear and anxiety is a common problem in pediatric patients. There is considerable variation in techniques used to manage them. Various sedation techniques using many different anesthetic agents have gained considerable popularity over the past few years. Children are not little adults; they differ physically, psychologically, and emotionally. The purpose of this review is to survey recent trends and concerning issues in the rapidly changing field of pediatric sedation. We will study the topic from the perspective of an anesthesiologist. It will also provide information to practitioners on the practice of conscious sedation in dentistry and will also outline the route of administration, pharmacokinetics, and pharmacodynamics of various drugs used.

Does sevoflurane add to outpatient procedural sedation in children? A randomised clinical trial

BACKGROUND

There is little evidence concerning the effect of sevoflurane in outpatient procedural sedation, especially in children. We hypothesised that the addition of sevoflurane to a sedation regimen improves children's behaviour with minimal adverse events.

METHODS

This is a randomised, triple-blind clinical trial conducted on an outpatient basis. Participants were 27 healthy children aged 4 to 6 years, who previously refused dental treatment with non-pharmacologic methods. All participants received oral midazolam (0.5 mg/kg, maximum 20 mg) and oral ketamine (3 mg/kg, maximum 50 mg) and, in addition: Group MK - 100% oxygen; Group MKS - inhalational sevoflurane at a sedative dose (final expired concentration between 0.3 and 0.4%). Dental appointments were video recorded for assessment of the children's sleep patterns, crying, movements, and overall behaviour during the procedure with the Houpt scale. Intra- and post-operative adverse events were systematically reported. Data were analysed by bivariate analyses in the IBM SPSS v. 19, at a significance level of 5%.

RESULTS

MK (n = 13) and MKS (n = 14) did not differ regarding the Houpt scores (P > 0.05), but 53.8% of children in the MK group showed hysterical and continuous crying at the time of the local anaesthesia injection, compared to 7.1% of children in the MKS group (P = 0.01; phi = 0.5). There was a trend toward less crying and movement over time during the dental appointment in the MKS group (P = 0.48). Minor adverse events were observed in 10 MK children and 4 MKS children (P = 0.01).

CONCLUSIONS

The addition of sevoflurane to oral midazolam-ketamine improved the children's crying behaviour during local anaesthetic administration, and did not increase the occurrence of adverse events.

TRIAL REGISTRATION

Clinical Trials NCT02284204 . Registered 5 October 2014.

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.

Dental fear in children: the role of previous negative dental experiences

OBJECTIVES

The aims of this study were to determine the potential main sources of anxiety in children visiting the dental office and to examine whether negative experiences influence the development of dental fear.

METHODS

Six hundred six subjects from the same pediatric dental office were consecutively invited to participate in the study (303 children/303 parents). An adapted version of the Wong-Baker FACES Pain Rating Scale and Corah's Dental Anxiety Scale were used to rate anxiety in children and parents. Clinical variables were collected by the same experienced pediatric dentist, with a view to determining their potential influence upon the development of fears. Descriptive statistics (mean, standard deviation), along with the Mann-Whitney U test, were used to determine the association between clinical variables and anxiety levels. Correlations were established using the Spearman coefficient (r) (p < 0.05).

RESULTS

No statistical differences were observed in anxiety levels with respect to patient gender (p > 0.05). Greater anxiety levels were observed in 4- and 5-year-old children (n = 56/55, respectively), with a negative correlation between age and anxiety level (r = -0.176; p = 0.002) and between parent anxiety level and patient age (r = -0.154; p = 0.007). A strong positive correlation was found between the anxiety levels of the parents and children (r = 0.954; p < 0.001). In addition, a moderate positive correlation was found between elevated anxiety levels in children (r = 0.381; p < 0.001) and parents (r = 0.454; p < .001) and the number of previous treatments in other dental offices.

CONCLUSIONS

Dental fear in children is strongly associated with inadequate dental management, causing anxiety levels to increase in both the children and parents.

A prospective, randomized controlled trial of conscious sedation using propofol combined with inhaled nitrous oxide for dental treatment

PURPOSE

Adverse reactions during propofol sedation include a decrease in arterial blood pressure, propofol-induced pain on injection, and airway complications. The purpose of this study was to investigate whether combined use of intravenous propofol and inhaled nitrous oxide could decrease the hypotensive and other adverse effects of propofol.

PATIENTS AND METHODS

We designed and implemented a prospective, randomized controlled trial. Patients undergoing dental procedures requiring intravenous sedation were randomly allocated to 2 groups: group P comprised those receiving sedation with propofol alone, and group N+P comprised those receiving sedation with 40% nitrous oxide inhalation and propofol. During the dental procedures, the sedation level was maintained at an Observer's Assessment of Alertness/Sedation scale score of 4 by adjusting propofol's target plasma concentration. Nitrous oxide inhalation was the predictor variable, whereas the hemodynamic changes, amount and concentration of propofol, and adverse events were the outcome variables.

RESULTS

Eighty-eight patients were successfully analyzed without any complications. The total amount of propofol was significantly less in group N+P (249.8 ± 121.7 mg) than in group P (310.3 ± 122.4 mg) (P = .022), and the mean concentration of propofol was significantly less in group N+P (1.81 ± 0.34 μg/mL) than in group P (2.05 ± 0.44 μg/mL) (P = .006). The mean blood pressure reduction in group N+P (11.0 ± 8.0 mm Hg) was significantly smaller than that in group P (15.8 ± 10.2 mm Hg) (P = .034). Pain associated with the propofol injection and memory of the procedure were less in group N+P (P = .011 and P = .048, respectively). Nitrous oxide did not affect respiratory conditions or recovery characteristics.

CONCLUSIONS

The results of this study suggest that nitrous oxide inhalation combined with propofol sedation attenuates the hypotensive effect and pain associated with propofol injections, along with potentiating the amnesic effect.

Effect of oral-transmucosal midazolam sedation on anxiety levels of 3-4 years old children during a Class II restorative procedure

AIM

A double-blind randomized control trial was conducted to assess the effect of oral-transmucosal midazolam sedation on changes in anxiety levels of precooperative children during a Class II amalgam restorative procedure.

METHODOLOGY

A sample of 40 healthy, American Society of Anesthesiologists I, children aged 3-4 years having at least one carious primary mandibular molar requiring a Class II amalgam restoration with no previous dental history were randomly divided into experimental and control groups comprising of 20 children each. The children in the experimental group (Group I) received 0.5 mg/kg body weight of midazolam mixed in strawberry syrup and those in the control group (Group II) received the same syrup mixed in saline, 15 min prior to the restorative procedure. Routine nonpharmacological behavior management techniques were used in both groups. The anxiety levels were recorded using Venham's anxiety scale at the start and end of each procedural step.

RESULTS

There was a significant (P < 0.001) reduction in the anxiety levels of children in the experimental group on entry into the operatory compared with the control group. Introduction of each fear evoking stimuli showed a somewhat similar increase in anxiety levels in the two groups. In spite of a similar trend, the anxiety levels remained much lower in Group I than in Group II.

CONCLUSION

Midazolam in conjunction with behavior management is more helpful in relaxing the child initially than behavior management alone, thus increasing the chances of successful and easy accomplishment of further treatment steps.

The use of anaesthetic agents to provide anxiolysis and sedation in dentistry and oral surgery

Throughout the world there is considerable variation in the techniques used to manage anxious dental patients requiring treatment. Traditionally anxious or phobic dental patients may have been sent for general anaesthesia to allow dental treatment be undertaken. While this is still the case for the more invasive oral surgical procedures, such as wisdom teeth extraction, sedation in general dentistry is becoming more popular. Various sedation techniques using many different anaesthetic agents have gained considerable popularity over the past 30 years. While the practice of sedating patients for dental procedures is invaluable in the management of suitably assessed patients, patient safety must always be the primary concern. Medical, dental and psychosocial considerations must be taken into account when evaluating the patient need and the patient suitability for sedation or general anaesthesia. The regulations that govern the practice of dental sedation vary throughout the world, in particular regarding the techniques used and the training necessary for dental practitioners to sedate patients. It is necessary for medical and dental practitioners to be up to date on current practice to ensure standards of practice, competence and safety throughout our profession. This article, the first in a two-part series, will provide information to practitioners on the practice of sedation in dentistry, the circumstances where it may be appropriate instead of general anaesthesia and the risks involved with sedation. It will also discuss the specific training and qualifications required for dental practitioners to provide sedation. The second article in this series will outline the different techniques used to administer inhalation, oral and intravenous sedation in dentistry and will focus on specific methods that are practiced.

Conscious sedation procedures using intravenous midazolam for dental care in patients with different cognitive profiles: a prospective study of effectiveness and safety

The use of midazolam for dental care in patients with intellectual disability is poorly documented. This study aimed to evaluate the effectiveness and safety of conscious sedation procedures using intravenous midazolam in adults and children with intellectual disability (ID) compared to dentally anxious patients (DA). Ninety-eight patients with ID and 44 patients with DA programmed for intravenous midazolam participated in the study over 187 and 133 sessions, respectively. Evaluation criteria were success of dental treatment, cooperation level (modified Venham scale), and occurrence of adverse effects. The mean intravenous dose administered was 8.8±4.9 mg and 9.8±4.1 mg in ID and DA sessions respectively (t-test, NS). 50% N₂O/O₂ was administered during cannulation in 51% of ID sessions and 61% of DA sessions (NS, Fisher exact test). Oral or rectal midazolam premedication was administered for cannulation in 31% of ID sessions and 3% of DA sessions (p<0,001, Fisher exact test). Dental treatment was successful in 9 out of 10 sessions for both groups. Minor adverse effects occurred in 16.6% and 6.8% of ID and DA sessions respectively (p = 0.01, Fisher exact test). Patients with ID were more often very disturbed during cannulation (25.4% ID vs. 3.9% DA sessions) and were less often relaxed after induction (58.9% ID vs. 90.3% DA) and during dental treatment (39.5% ID vs. 59.7% DA) (p<0.001, Fisher exact test) than patients with DA. When midazolam sedation was repeated, cooperation improved for both groups. Conscious sedation procedures using intravenous midazolam, with or without premedication and/or inhalation sedation (50% N₂O/O₂), were shown to be safe and effective in patients with intellectual disability when administered by dentists.

Assessment and management of chronic orofacial pain associated with a disease in children: a multidisciplinary approach

To summarize the diversity of assessment and management for chronic orofacial pain associated with a disease (COFPAD) in children. We performed a review of the literature up to May 2012. Hetero-evaluation and self-assessment are used according to age of children. Strict management of the cause is not sufficient for children with COFPAD without a multidisciplinary approach combining pharmacotherapy, psychology and physiotherapy.

CONCLUSION

The multidisciplinary approach is the key of management for children with COFPAD.

Applications of nitrous oxide for procedural sedation in the pediatric population

OBJECTIVE

The objective of this review was to provide a general descriptive account of the physical properties, end-organ effects, therapeutic applications, and delivery techniques of nitrous oxide (N2O) as used in the arena of procedural sedation.

DATA SOURCE

A computerized bibliographic search regarding the applications of nitrous for provision of sedation and analgesia during procedures with an emphasis on the pediatric population was performed.

RESULTS

The end-organ effects of N2O have been well described in the operating room setting. Aside from its effects on the central nervous system of sedation and analgesia, N2O may alter intracerebral dynamics and alter cerebral blood flow and intracranial pressure especially in patients with altered intracranial compliance. Effects on ventilation include a dose-related depression of ventilatory function and control of upper airway patency. These effects are generally limited in the absence of comorbid diseases and potentiated by other sedative and analgesic agents. The more clinically significant respiratory effect of N2O on ventilatory function is a dose-dependent depression of the ventilatory response to hypoxemia. Hemodynamic effects include a mild direct depressant effect on myocardial function, which in the absence of comorbid cardiac disease is generally compensated by stimulation of the sympathetic nervous system. Nitrous oxide may potentially aggravate pulmonary hypertension. Additional physiologic effects on neurologic and hematologic function may result in inactivation of the enzyme, methionine synthetase. Recent concern has also been raised regarding the potential effects of N2O on immune function and its relationship to perioperative surgical site infections. Given differences in the solubility, N2O will diffuse into and significantly expand gas-filled cavities. Chronic exposure of health care works to N2O is also a concern. Although there are limited data in the literature to clearly substantiate concerns regarding the reproductive toxicity of occupational exposure to N2O, appropriate scavenging and use of other techniques are mandatory. Nitrous oxide has been shown to be effective for a variety of minor surgical procedures such as venipuncture, intravenous cannula placement, lumbar puncture, bone marrow aspiration, laceration repair, dental care, and minor dermatologic procedures. It is generally as effective as midazolam, with several studies demonstrating it to be more effective. However, its utility is not as great in severely painful procedures such as fracture reduction. Demonstrated advantages to parenteral sedation include a more rapid onset and a shorter recovery time with the majority of patients preferring it to over other agents or agreeing to its use for subsequent procedures. The literature also suggests increased success rates with simple procedures such as intravenous cannula placement when compared with placebo. In general, life-threatening adverse events have not been reported. Most common adverse effects include dysphoria and vomiting. For more painful procedures, combination with another agent may be used, and in all cases, topical or infiltrative local anesthesia is recommended.

CONCLUSIONS

In general, N2O is a useful adjunct for procedural sedation. Given the variety of procedures performed in the pediatric patient, ongoing research is required to identify the most appropriate and effective use of this agent. This may be particularly relevant when evaluating its use for procedures associated with significant pain. In these scenarios, the combination of N2O with other agents needs to be evaluated. Given the potential for adverse effects, strict adherence to published guidelines regarding procedural sedation and monitoring is suggested.

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.

Paediatric conscious sedation: views and experience of specialists in paediatric dentistry

OBJECTIVES

The objectives were three-fold: to investigate the level of conscious sedation training received prior to and during specialist training in paediatric dentistry; to establish the use of conscious sedation during and following specialisation; and to determine the attitudes of specialists in paediatric dentistry to conscious sedation.

SUBJECTS AND METHODS

A self-administered postal questionnaire was sent to all specialists in paediatric dentistry registered with the General Dental Council in January 2008. Non-responders were contacted again after a four-week period.

RESULTS

A response rate of 60% was achieved. Of the 122 respondents, 67 (55%) had received sedation training as an undergraduate; 89 (75%) had been trained during specialisation. All respondents performed dental treatment under sedation as a trainee and the majority used nitrous oxide inhalation sedation (NOIS). Over 90% of respondents felt that NOIS should be available to all children, both in appropriate primary care settings and in hospitals. One hundred and twenty-one (99%) respondents thought that all trainees in paediatric dentistry should have sedation training.

CONCLUSIONS

The most popular form of sedation amongst specialists in paediatric dentistry was NOIS. However, some of the respondents felt that children should have access to other forms of sedation in both the primary care and hospital settings. Additional research on other forms of sedation is required to evaluate their effectiveness and safety.

A comparison of the 'cost per child treated' at a primary care-based sedation referral service, compared to a general anaesthetic in hospital

AIM

To compare the cost-effectiveness of dental sedation techniques used in the treatment of children, focusing on hospital-based dental general anaesthetic (DGA) and advanced conscious sedation in a controlled primary care environment.

METHODS

Data on fees, costs and treatment pathways were obtained from a primary care clinic specialising in advanced sedation techniques. For the hospital-based DGA cohort, data were gathered from hospital trusts in the same area. Comparison was via an average cost per child treated and subsequent sensitivity analysis.

RESULTS

Analysing records spanning one year, the average cost per child treated via advanced conscious sedation was pound245.47. As some treatments fail (3.5% of cases attempted), and the technique is not deemed suitable for all patients (4-5%), DGA is still required and has been factored into this cost. DGA has an average cost per case treated of pound359.91, 46.6% more expensive than advanced conscious sedation. These cost savings were robust to plausible variation in all parameters.

CONCLUSION

The costs of advanced conscious sedation techniques, applied in a controlled primary care environment, are substantially lower than the equivalent costs of hospital-based DGA, informing the debate about the optimum way of managing this patient group.

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.

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.