How Do Observational Scales Correlate the Ratings of Children's Behavior during Pediatric Procedural Sedation?

The relationship between overprotective parenting, toothbrushing practices and children's behaviour during dental treatments in 4 to 11-year-old Dutch children: a cross sectional study

PURPOSE

Overprotective parenting and its impact on child development has gained increasing public attention. This study explored the association between overprotective parenting and behaviour during dental treatments and toothbrushing behaviour of 4 to 11-year-old-children.

METHODS

In this cross-sectional study, caregivers of 4-to-11-year-old children who visited a referral practice for dental treatment in Leiden, The Netherlands, completed a questionnaire about overprotective parenting, using the Parental Overprotection Measure (POM), and children's toothbrushing behaviour. The dentist and dental assistant used the Venham scale to assess children's behaviour during dental treatments. Associations between the POM and the Venham scale and toothbrushing variables, were analysed using multiple ordered logistic regression.

RESULTS

The sample included 96 children (mean age: 7.3 ± 2.1 years, 59 boys). Overprotective parenting (higher POM scores) was significantly associated with more disruptive behaviour of children during dental treatments (higher Venham categories) (OR: 1.08 (95% CI 1.04; 1.13)) and lower caregiver self-efficacy regarding toothbrushing (OR 0.96 (95% CI 0.93; 0.99)), after adjustment for confounders. No associations between overprotective parenting and toothbrushing frequency or skipping toothbrushing were found.

CONCLUSIONS

Overprotective parenting has been associated with children's negative behaviour during dental treatments and lower caregiver self-efficacy regarding toothbrushing in primary school children who are treated in a referral practice for paediatric dental care.

Efficacy of continuous intravenous remimazolam versus midazolam in the extraction of impacted wisdom teeth: protocol of a randomised controlled trial

INTRODUCTION

Benzodiazepines such as midazolam are widely used to moderately sedate patients during impacted wisdom tooth extraction to reduce anxiety in outpatient surgery. This present protocol was designed to determine whether continuous intravenous remimazolam, a new ultrashort-acting benzodiazepine, produces superior postoperative recovery quality to that of midazolam in patients undergoing extraction of impacted wisdom teeth.

METHODS AND ANALYSIS

This study is a multicentre randomised controlled trial conducted at Peking Union Medical College Hospital, Beijing Anzhen Hospital and Beijing Shijitan Hospital in China. Approximately 150 participants undergoing extraction of impacted mandibular wisdom teeth will be randomly allocated to two groups (remimazolam and midazolam). The participants will be administered standard interventions to ensure they achieve a sedation level of III on the Ramsay sedation scale during the treatment. Preoperative and anaesthesia management and surgical techniques will be standardised for all participants. The primary outcome is recovery time for complete alertness and the secondary outcomes are anterograde amnesia during and after surgery, and interruption during operation for poor compliance or safety concerns.

ETHICS AND DISSEMINATION

This study has been approved by the Ethics Review Committee of Peking Union Medical College Hospital (approval number: ZS-3142), Beijing Anzhen Hospital (approval number: KS2022082) and Beijing Shijitan Hospital (approval number: 2023-4).

TRIAL REGISTRATION NUMBER

NCT05350085.

Behavioral Modifications in Children after Repeated Sedation with Nitrous Oxide for Dental Treatment: A Retrospective Study

Sedation with nitrous oxide (N₂O) has been widely used as a viable alternative to general anesthesia to perform dental treatments in uncooperative or anxious children. The purpose of this retrospective study is to assess if repeated sedations with N₂O can improve collaboration of uncooperative children. The medical records of 650 children, aged between 3 and 14 years, who underwent at least two sedations, were consulted. Differences in the Venham score during the first sedation and subsequent sedations were collected. After removal incomplete records, 577 children's records (309 males and 268 females) were analyzed. The Venham score decreased both during each sedation and with repeated sedations (p < 0.01 for both comparisons). In particular, a significant reduction of the Venham score was observed at the first contact with the dentist, with a mean score ranging from 1.56 ± 1.46 to 1.16 ± 1.37, comparing the first and the second sedation, and from 1.65 ± 1.43 to 1.06 ± 1.30, comparing the first with the third sedation (p < 0.01). The reduction in the Venham score was recorded in both healthy and physically impaired patients, and it was significantly greater in older children than in younger children (p < 0.01). In conclusion, uncooperative children with or without physical impairments can be successfully treated with N₂O sedation in order to increase their confidence in dental procedures.

Roller microneedles transdermal delivery of compound lidocaine cream for enhancing the analgesic effect: A randomized self-controlled trial

OBJECTIVE

The purpose of this article is to investigate whether the percutaneous delivery of compound lidocaine cream by roller microneedles can shorten the minimal effective onset time of anesthesia, enhance the intensity of anesthesia and prolong the analgesic time, so as to provide a theoretical basis for exploring a comfortable, safe and effective anesthesia method for photoelectric cosmetic surgery.

METHODS

A total of 90 healthy volunteers, including 18 male and 72 female, met the criteria and were enrolled in the study from December 2020 to September 2021 in Department of Plastic and Burn Surgery of the First Affiliated Hospital of Chongqing Medical University. This study adopted a two-factor randomized block design of 3 (anesthesia time on the test side: 30, 45, 60 min) × 2 (the test side: the left and right side), and the subjects were divided into group A (n = 30), group B (n = 30), and group C (n = 30). On the test side, the compound lidocaine cream was used for topic anesthesia for 10 min, then the roller microneedle was used to roll on the treatment area, compound lidocaine cream was appropriately supplemented, and the topic anesthesia was kept continued for 20 min (group A), 35 min (group B), and 50 min (group C), respectively. The mirrorsymmetrical area of the test side of the three groups was the control side, and the compound lidocaine cream was used for topic anesthesia for 60 min. Photoelectric therapy was performed after anesthesia was completed. The analgesic effect of the subjects on both sides was comprehensively compared; the scores were obtained using the Kuttner Facial Expression Scale, the Frankl Treatment Compliance Scale, the Houpt Behavior Scale, and the Visual Analog Scale (VAS); the satisfaction with anesthesia was investigated. Before and after treatment the skin temperature, color and adverse reactions of the subjects were recorded.

RESULTS

Comparing both sides of the same group, there was no significant difference in terms of the comprehensive evaluation, intraoperative comfort, tolerance, cooperation, pain or satisfaction between the 30-min test side and the routine anesthesia side in group A; the comprehensive evaluation, intraoperative tolerance, cooperation degree, pain degree and satisfaction evaluation of the subjects on the 45-min test side in group B were significantly better than those on the control side; the comprehensive evaluation, intraoperative comfort, tolerance, cooperation, pain and satisfaction of the subjects on the 60-min test side in group C were significantly better than those on the control side. Comparing groups on the control side, there was no significant difference in the comprehensive evaluation, intraoperative comfort, tolerance, cooperation, pain or satisfaction between the three groups of subjects on the control side. Comparing the three groups on the test side, with the prolongation of compound lidocaine cream indwelling time, the subjects' comprehensive evaluation, comfort and pain degree were significantly improved. There was no significant difference in postoperative bruising, swelling, pain, discoloration, redness, or tenderness between the test side and the control side.

CONCLUSION

The percutaneous delivery of compound lidocaine cream by roller microneedles can not only shorten the effective time of anesthesia, but also has a good analgesic effect without obvious adverse reactions.

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

BACKGROUND

There is a lack of evidence on the effectiveness of moderate sedation in pediatric dentistry, compared to protective stabilization, which remains routinely used in Brazil despite moral questions. This prospective non-randomized clinical trial's objective is to evaluate the effectiveness of moderate sedation, compared to the protective stabilization, in the dental care of children with dental behavior management problems.

METHODS

Participants will be 152 children under seven years of age with early childhood caries (ECC) who need specialized dental treatment due to a history of challenging behavior during dental care. The interventions to be compared are moderate sedation with oral administration of ketamine and midazolam and protective stabilization. The primary endpoint will be the child's behavior during treatment assessed using the Ohio State University Behavioral Rating Scale (OSUBRS). The secondary outcomes are (A) child's - behavior according to the visual analogue scale, anxiety, pain, and physiological stress; (B) parent's - satisfaction and anxiety; (C) family and child - impact on oral health-related quality of life (OHRQoL); (D) dentist's - satisfaction and stress; (E) procedure - adverse events of the intervention and dental treatment longevity. A cost-effectiveness analysis will be performed from the perspective of the Brazilian Unified Health System (SUS).

DISCUSSION

Considering the primary outcome, this study hypothesis is that sedated children have better behavior during dental treatment than children whose behavior was managed by protective stabilization without sedation. Additionally, at the end of 12 months, we expect to identify participants' reported outcomes and objective measures related to dental behavior in early childhood. Trial registration Clinicaltrials.gov registration NCT04119180 on October 8th, 2019. https://clinicaltrials.gov/ct2/show/NCT04119180.

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

BACKGROUND

Patient-reported outcomes are under-investigated in the field of paediatric dental sedation.

AIM

To evaluate the satisfaction of parents/guardians with their children's dental sedation, compare it to the dentist's satisfaction, and identify associated factors.

DESIGN

This study was performed with parents/guardians of young children treated under sedation and dentists. Participants' satisfaction was measured using the visual analogue scale (0-100). Child's behaviour was classified using the Ohio State Behavioural Rating Scale. Other information was collected during interviews and from patient charts. The Spearman's, Mann-Whitney and Kruskal-Wallis tests were performed (P < .05).

RESULTS

A total of 167 parents/guardians and ten dentists participated in the study. Protective stabilisation and atraumatic restorative treatment (ART) were used in 69.9% and 51.5% appointments, respectively. The parents/guardians (median: 91 [25-75 percentile: 75-96]) and dentists (76 [23-98]) were satisfied. Parental/guardian satisfaction was higher than dentist satisfaction (P ≤ .001). Parental/guardian satisfaction was positively correlated with quiet child behaviour (r = 0.347, P ≤ .001) and was associated with the non-use of protective stabilisation (P ≤ .001), no previous toothache (P = .019), and the use of ART (P = .018).

CONCLUSION

The participants were satisfied with treatment under sedation. Parents/guardians were more satisfied, especially, when the child had cooperative behaviour.

Comparison of the Efficacy of Jilo Animation Approach versus Conventional Tell-Show-Do (TSD) Technique on Cooperation and Anxiety Levels of Children during Dental Practice: A Randomized Controlled Clinical Trials

Statement of the Problem

Modeling is one of the non-pharmacological approaches to manage anxiety behavior and encourage children's cooperation in dentistry. This method is based on social learning theory in which the children learn the skills of overcoming anxiety and adapting their skills and behaviors during dental treatment.

Purpose

The aim of this study was to evaluate the effect of an animated-movie modeling approach, named Jilo, on cooperation and anxiety of children in comparison with the conventional Tell-Show-Do (TSD) method in a dental setting.

Materials and Method

In this randomized controlled trial, 50 healthy children (aged 4-6) with no history of dental treatment were recruited and randomly allocated to experimental (n= 24) and control (n= 24) groups. During the first visit, the experimental group watched the Jilo animated movie. After a 30-minute break, they received prophylaxis followed by fluoride therapy. The control group received the conventional TSD technique and then underwent prophylaxis and fluoride therapy. One week later, a dental restoration, which required mandibular nerve block anesthesia, was performed for both groups. The cooperation and anxiety levels of patients were evaluated during two visits using Venham Clinical Cooperation Scale (VCCS) and Venham Clinical Anxiety Scale (VCAS).

Results

The mean VCAS in the experimental group was significantly lower compared to the control group during the first and second visits (p= 0.008 and p= 0.044, respectively). The mean VCCS was also significantly lower in the experimental group during the first (p= 0.015) and second visits (p= 0.019) compared to the control group.

Conclusion

The application of animated-movie modeling (Jilo) can be recommended as an effective method for preparation of children before the dental treatment session.

Child behaviour during dental care under nitrous oxide sedation: a cohort study using two different gas distribution systems

Purpose

Conscious sedation by inhalation of a mixture of nitrous oxide and oxygen (CS) is a technique used in dental care for anxious, handicapped or uncooperative patients. The very special objective of this cohort study is to compare the behaviour of young patients during dental care under CS in two hospitals using different gas distribution systems.

Methods

Young patients were divided into four categories: young child (YC), phobic anxiety (PA), mental disorder (MD), occasional indication (OI). Differences in behaviour scale at various time points according to the sedation system used were established and compared using Mann–Whitney tests.

Results

This study showed that there is no difference in behaviour during dental care in YC after sedation. In PA, a significant difference in behaviour is only observed during local anaesthesia (p = 0.024).

Conclusion

No significant differences detected in children’s behaviour under conscious sedation using different gas administration systems. The delicate stage of local anaesthesia in PA patients can be facilitated with repeated sessions of dental care under conscious sedation.

Electronic supplementary material

The online version of this article (10.1007/s40368-020-00569-z) contains supplementary material, which is available to authorised users.

Randomized clinical trial on the efficacy of intranasal or oral ketamine-midazolam combinations compared to oral midazolam for outpatient pediatric sedation

Purpose

The optimal sedative regime that provides the greatest comfort and the lowest risk for procedural sedation in young children remains to be determined. The aim of this randomized, blinded, controlled, parallel-design trial was to evaluate the efficacy of intranasal ketamine and midazolam as the main component of the behavioral guidance approach for preschoolers during dental treatment.

Materials and methods

Children under seven years of age, with caries and non-cooperative behavior, were randomized into three groups: (KMIN) intranasal ketamine and midazolam; (KMO) oral ketamine and midazolam; or (MO) oral midazolam. The dental sedation appointments were videotaped, and the videos were analyzed using the Ohio State University Behavioral Rating Scale (OSUBRS) to determine the success of the sedation in each group. Intra- and postoperative adverse events were recorded. Data analysis involved descriptive statistics and non-parametric tests (P < 0.05, IBM SPSS).

Results

Participants were 84 children (28 per group; 43 boys), with a mean age of 3.1 years (SD 1.2). Children’s baseline and the dental sedation session characteristics were balanced among groups. The success of the treatment as assessed by the dichotomous variable ‘quiet behavior for at least 60% of the session length’ was: KMIN 50.0% (n = 14; OR 2.10, 95% CI 0.71 to 6.30), KMO 46.4% (n = 13; OR 1.80, 95% CI 0.62 to 5.40), MO 32.1% (n = 9) (P = 0.360). Adverse events were minor, occurred in 37 of 84 children (44.0%), and did not differ among groups (P = 0.462).

Conclusion

All three regimens provided moderate dental sedation with minor adverse events, with marked variability in the behavior of children during dental treatment. The potential benefit of the ketamine–midazolam combination should be further investigated in studies with larger samples.

Trial registration

ClinicalTrials.gov, identifier: NCT02447289. Registered on 11 May 2015, named “Midazolam and Ketamine Effect Administered Through the Nose for Sedation of Children for Dental Treatment (NASO).”

Intranasal sedation using ketamine and midazolam for pediatric dental treatment (NASO): study protocol for a randomized controlled trial

BACKGROUND

Uncooperative children may need to receive dental treatment under sedation, which is indicated when nonpharmacological behavior guidance is unsuccessful. There are randomized controlled trials (RCTs) comparing different sedative protocols for dental procedures; however, the evidence for superiority of one form over another is weak. The primary aim of this study is to investigate the efficacy of intranasally administered ketamine plus midazolam for the dental treatment of children.

METHODS

We have designed a three-armed, parallel RCT to assess intranasal sedation using ketamine/midazolam in terms of the following measures: efficacy, safety, and cost-effectiveness. Two- to 6-year-old healthy children, referred for dental treatment in a dental sedation center in Brazil due to uncooperative behavior and requiring restorative dental procedures, will be recruited. Each child will be randomly assigned to one of the three groups: A - Intranasal administration of ketamine (4.0 mg/kg, maximum 100 mg) and midazolam (0.2 mg/kg, maximum 5.0 mg); B - Oral administration of ketamine (4.0 mg/kg, maximum 100 mg) and midazolam (0.5 mg/kg, maximum 20 mg); and C - Oral administration of midazolam (1.0 mg/kg, maximum 20 mg). The primary outcome is the child's behavior assessed through an observational scale using digital videos of the restorative dental treatment under sedation. The secondary outcomes are as follows: acceptance of sedative administration; memory of intraoperative events; the child's stress; adverse events; the child's pain during the procedure; the parent's, dentists', and child's perceptions of sedation; and economic analysis. Measures will be taken at baseline and drug administration and during and after the dental procedure. The necessary sample size was estimated to be 84 children after a blinded interim analysis of the first 30 cases.

DISCUSSION

This study will provide data that can substantially add to science and pediatric dentistry as it examines the effect of sedative regimes from different perspectives (outcomes).

TRIAL REGISTRATION

ClinicalTrials.gov, identifier: NCT02447289 . Registered on 11 May 2015, named "Midazolam and Ketamine Effect Administered Through the Nose for Sedation of Children for Dental Treatment (NASO)."