Invasive 'placebo' controls: have we lost sight of whom we are blinding?

Children's discomfort may vary among different treatments for initial approximal caries lesions: preliminary findings of a randomized controlled clinical trial

BACKGROUND

Longer and more complex dental procedures could negatively affect patient's acceptability of minimal invasive techniques.

AIMS AND METHODS

Therefore, this short communication aims to show the preliminary findings regarding children's discomfort reported after some minimal invasive treatments in treating initial caries lesions on approximal surfaces: flossing instruction, silver diamine fluoride (SDF) application and caries resin infiltration.

RESULTS

Children allocated in the infiltration group showed higher levels of discomfort than those in the SDF and control groups.

CONCLUSIONS

These findings suggest that the simplest interventions for approximal initial caries lesions cause less discomfort for children and should be applied where possible.

New proposal of silver diamine fluoride use in arresting approximal caries: study protocol for a randomized controlled trial

BACKGROUND

Approximal surfaces are a challenge to caries lesions control. Silver diamine fluoride (SDF) is a simple,low-cost and promisor intervention for arresting caries lesions, but it has never been tested on approximal surfaces. Our aim is to evaluate the efficacy and cost-efficacy of SDF in arresting initial lesions compared to resin infiltration and exclusively flossing (control group). Our second aim is to assess discomfort and satisfaction regarding interventions.

METHODS/DESIGN

This is a randomized clinical trial, double-blinded, placebo-controlled study. Children/adolescents presenting at least one approximal initial caries lesion in primary molars/permanent premolars and molars will be included. Surfaces with advanced dentine lesions identified by radiography and participants who refuse to participate or present negative behaviors will be excluded. A minimum sample size of 504 surfaces will be required for each subgroup. Individuals will be randomly allocated in three groups of interventions: SDF, resin infiltration, and control group. Depending on the allocation, the patients will receive the active treatment and respective placebo therapies. All patients will be oriented to daily flossing the included surfaces. Our primary outcome will be caries progression by clinical and radiographic examinations. Appointments will be timed and costs of materials will be considered to calculate cost-efficacy. Patient discomfort will be assessed after interventions. Parent and patient satisfaction with the treatment will be collected after treatment and in the last follow-up visit. Individuals will be assessed at 1 and 3 months after treatment to evaluate dental biofilm and at 6, 12, and 24 months to assess caries progression by visual examination and/or radiography. Multilevel analyses will be used to verify if the type of treatment influenced on the tested outcomes. Costs will be compared and analyses of cost-efficacy will be performed. Poisson analysis will test the association between intervention and reported discomfort and satisfaction.

DISCUSSION

Our hypothesis is that SDF is the most cost-efficacious option from all tested interventions. If our hypothesis is confirmed, the use of SDF in private and public contexts could represent an easier and effective option in the treatment of enamel approximal caries in children/adolescents.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT01477385), Initial release: 11/16/2011: last update: 06/02/2014.

Bilateral Suprazygomatic Maxillary Nerve Block for Cleft Palate Repair in Children

Background:

The authors investigated the efficacy of bilateral suprazygomatic maxillary nerve block (SMB) for postoperative pain relief in infants undergoing cleft palate repair.

Methods:

In this prospective, double-blind, single-site, randomized, and parallel-arm controlled trial, 60 children were assigned to undergo bilateral SMB with general anesthesia with either 0.15 ml/kg of 0.2% ropivacaine (Ropi group) or 0.15 ml/kg of isotonic saline (Saline group) on each side. The primary endpoint was total postoperative morphine consumption at 48 h. Pain scores and respiratory- and SMB-related complications were noted.

Results:

The overall dose of intravenous morphine after 48 h (mean [95% CI]) was lower in the Ropi group compared with that in the Saline group (104.3 [68.9 to 139.6] vs. 205.2 [130.7 to 279.7] μg/kg; P = 0.033). Continuous morphine infusion was less frequent in the Ropi group compared with that in the Saline group (1 patient [3.6%] vs. 9 patients [31%]; P = 0.006). Three patients in the Saline group had an episode of oxygen desaturation requiring oxygen therapy. There were no technical failures or immediate complications of the SMB. Intraoperative hemodynamic parameters, doses of sufentanil, pain scores, and postoperative hydroxyzine requirements were not different between the two groups.

Conclusion:

Bilateral SMB is an easy regional anesthesia technique that reduces total morphine consumption at 48 h after cleft palate repair in children and the use of continuous infusion of morphine and may decrease postoperative respiratory complications.

[Informed consent for standard procedures and for clinical research in paediatric anaesthesia]

This short review is aimed at describing the particularities of consent in paediatric patients. For routine procedures, the consent of one of the parents is required whereas both parents should sign the consent for research protocols. In case of difficulties such as Jehovah witnesses or parental opposite opinions, doctors should ask the question to the judge in charge of protection of children. Consent or at least assent of minors enrolled in research protocols should be obtained provided their maturity is sufficient to understand correctly the purpose of clinical research.