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

Experiences of dental behaviour support techniques: A qualitative systematic review

BACKGROUND

Little is known about patients' or carers' reported experiences of dental care provided using dental behaviour support (DBS) techniques. Qualitative literature can provide unique insight into these experiences.

AIM

To explore and synthesize qualitative literature related to patient experience of dental behaviour support.

METHODS

A PROSPERO-registered systematic review of qualitative articles was undertaken. Studies were identified through MEDLINE, Embase and PsycINFO. Abstracts were screened by two reviewers and data were extracted to summarize the qualitative findings included within them. A thematic summary approach was used to synthesize the qualitative data identified.

RESULTS

Twenty-three studies were included. Studies primarily explored experiences of dental care of children by speaking to their parents (n = 16), particularly regarding paediatric dental general anaesthesia (DGA) (n = 8). Studies of adults' experiences of DBS (n = 7) covered a range of techniques. Nine studies explored broader dental care experiences and did not study specific DBS approaches. A thematic synthesis identified five themes applicable across the studies identified: Trust and the therapeutic alliance supporting effective care delivery; considered information sharing often alleviated anticipatory anxiety; control and autonomy-reduced anxieties; variations in the perceived treatment successes and failures of DBS techniques; and DBS techniques produced longer positive and negative impacts on patients beyond direct care provision.

CONCLUSION

Qualitative research has been under-utilized in research on DBS techniques. Care experiences of most DBS techniques outside of paediatric DGA are poorly understood. Building trust with patients and enabling autonomy appear to support positive patient-reported experiences of care.

Anaesthetics and time perception: A review

Consciousness requires subjective experience in the "now." Establishing "now," however, necessitates temporal processing. In the current article, we review one method of altering consciousness, anaesthetic drug administration, and its effects on perceived duration. We searched PubMed, PsycInfo, and ScienceDirect databases, and article reference sections, for combinations of anaesthetic drugs and time perception tasks, finding a total of 36 articles which met our inclusion criteria. We categorised these articles with regard to whether they altered the felt passage of time, short or long interval timing, or were motor timing tasks. We found that various drugs alter the perceived passage of time; ketamine makes time subjectively slow down while GABAergic drugs make time subjectively speed up. At a short interval there is little established evidence of a shift in time perception, though temporal estimates appear more variable. Similarly, when asked to use time to optimise responses (i.e., in motor timing tasks), various anaesthetic agents make timing more variable. Longer durations are estimated as lasting longer than their objective duration, though there is some variation across articles in this regard. We conclude by proposing further experiments to examine time perception under altered states of consciousness and ask whether it is possible to perceive the passage of time of events which do not necessarily reach the level of conscious perception. The variety of methods used raises the need for more systematic investigations of time perception under anaesthesia. We encourage future investigations into the overlap of consciousness and time perception to advance both fields.

Evaluating the Quality of Systematic Reviews on Pediatric Sedation in Dentistry: An Umbrella Review

Sedation is a depression of a patient's state of consciousness, induced by medications, that can reach different levels of intensity during a medical procedure. Conscious sedation produces a minimally depressed level of consciousness without impairment of the ability to maintain an open airway, of protective reflexes or of responses to verbal and physical stimulation. This umbrella review is aimed at critically assessing the available systematic reviews (SRs) and meta-analyses (MA) on sedation in children/adolescents. An electronic database search was conducted that included Pubmed-Medline, Web of Science, Cochrane, Scopus, Scielo, Embase, LILACS and TRIP and the scope of which extended until January 2023. The risk of bias (RoB) of SRs was analyzed using the Measurement Tool to Assess SRs criteria 2 (AMSTAR2). Of 998 entries, 37 SRs were included. In terms of methodological quality, eight studies were assessed as having critically low quality, four studies had low quality, nine studies had moderate quality, and sixteen were considered to be of high quality. Based on the current guidelines, the most employed drugs in pediatric dentistry for sedation are nitrous oxide and midazolam; however, the available evidence supporting their use is insufficient and of low/critically low quality. The combined technique is recommended (nitrous oxide (30-50%) + midazolam). The optimal dose of oral midazolam is 0.75 mg/kg. The level of methodological quality of SRs is expected to increase according to the results and future directions of this umbrella review.

The role of anxiety in patients with hereditary angioedema during oral treatment: a narrative review

Objective

The present study investigated the clinical potential of managing anxiety during dental procedures to reduce acute attacks in patients with hereditary angioedema (HAE). HAE is a rare disease, little known to physicians and dentists, but with an increased hospitalization rate over the years. HAE is due to a deficiency/dysfunction of the C1 esterase inhibitor, leading to increased vascular permeability. Recommendations for HAE management include long-term and short-term prophylaxis and treatment of acute attacks, but the importance of anxiety control is underestimated.

Materials and methods

The authors reviewed the literature to provide the scientific community with an overview of possible protocols for managing anxiety in dental practice and their effectiveness. Management can be used in prosthetics, periodontal and implant surgery, endodontics, and oral surgery.

Discussions

Our analysis shows that although there are few articles in the indexed literature, protocols for managing anxiety in HAE patients in dentistry will become increasingly prevalent in the daily clinical practice of dentists due to its benefits.

Conclusions

The benefits and better control of intraoperative complications and risks may lead clinicians to use sedation, assessment, or anxiety control techniques in daily clinical practice to reduce such attacks. Clinical relevance: This study suggests that controlling and managing anxiety can help prevent and reduce acute angioedema attacks.

Trends of conscious sedation in the Department of Pediatric Dentistry at the Dankook University Dental Hospital for 11 Years

Background

Anxiety and fear in children's dental care are major impediments to successful dental care. High-quality dental treatment can be achieved using various behavioral control methods; however, conscious sedation using drugs can be used if behavioral control is difficult, owing to excessive fear and anxiety. This study aimed to examine the trends in conscious sedation implemented in pediatric dentistry at the Dankook University Dental Hospital over the past 11 years.

Methods

This study included 6,438 cases of dental treatment under conscious sedation conducted over 11 years between January 2011 and December 2021 in the Department of Pediatric Dentistry at Dankook University Dental Hospital.

Results

Over the past 11 years, the number of dental treatments under sedation has increased. In the case of inhalation sedation using nitrous oxide, the rate of increase was approximately twice every year, and the use of midazolam gradually decreased. The average age of children who underwent sedation was 5.11 years, and the rate of sedation treatment in children aged <4 years tended to decrease, while that of children aged >5 years tended to increase. This is related to the trend of changes in drugs used. In a sex-based survey, sedation treatment rate was higher in males than that in females.

Conclusion

Appropriate selection of sedatives can reduce the frequency of general anesthesia and minimize complications through efficient and safe dental treatments. Trend analysis of sedation by year will help provide guidelines for the appropriate selection of sedation for dental treatment of children and patients with disability.

Effects of Midazolam on Antioxidant Levels, Biochemical and Metabolic Parameters in Eurygaster integriceps Puton (Hemiptera: Scutelleridae) Eggs Parasitized by Trissolcus semistriatus Nees (Hymenoptera: Scelionidae)

Eurygaster integriceps Puton (Hemiptera: Scutelleridae) is among the most important insect pests of wheat (Triticum sativum L.) and barley (Hordeum vulgare L.) grown in the Middle East. Biological and chemical methods are insufficient to control E. integriceps populations below economic thresholds. In this study, we investigated the effects of midazolam, a clinical drug, on selected metabolic enzyme activity, antioxidant levels, and biochemical parameters in E. integriceps eggs parasitized by Trissolcus semistriatus Nees (Hymenoptera: Scelionidae). Increasing concentrations of midazolam caused cell damage in the parasitized eggs due to its oxidative effects. Transferase enzymes, such as, aspartate transferase, alanine transferase, and gamma glutamyl transferase activities were altered following exposure. Metabolic enzymes, such as, creatine kinase, alkaline phosphatase, amylase, and lactate dehydrogenase also were adversely affected. Levels of the non-enzymatic antioxidants uric acid, bilirubin, and albumin also were altered.

Effectiveness of nitrous oxide sedation for otolaryngologic examination in the outpatient clinic in uncooperative children

OBJECTIVES

The aim of this study is to investigate the efficacy of equimolar mixture of 50% nitrous oxide and oxygen (EMONO) to obtain conscious sedation for otolaryngologic examinations and minor Ear-Nose-Throat (ENT) procedures in children with or without comorbidities.

METHODS

Retrospective analysis of patient records from all children who were uncooperative during routine ENT examination, and therefore underwent otomicroscopic examinations and/or minor ENT procedures sedated with EMONO in the outpatient ENT clinic. The following data were collected: patients characteristics, sedative effect, analgesic effect and adverse effects. Patients were divided into three subgroups: 1) no relevant comorbidities, 2) Down Syndrome and 3) other causes of behavioural problems or developmental delay.

RESULTS

Data were analyzed for 99 patients (170 procedures). Seven procedures failed. A good to excellent sedative and analgesic effect was obtained in most patients without a difference between subgroups. Minor and transient side effects were encountered in one third (34%) of the patients.

CONCLUSIONS

EMONO is an effective agent to achieve conscious sedation and to perform ENT examinations or minor procedures in otherwise uncooperative children with or without developmental delay.

Current status of nitrous oxide use in pediatric patients

Nitrous oxide is one of the most commonly used inhalational anesthetic agents used in practice. It is a cost-effective, pleasant, safe, and versatile anesthetic agent with many desirable properties like good quality analgesia, decreased awareness, accelerated induction and recovery from anesthesia, and reduced utilization of other expensive inhalational agents with potential cost savings. The use of nitrous oxide has been questioned by a lot of studies and case reports perceiving its adverse systemic, hematological, immune, and neurologic adverse effects. However, the literature in the recent past has tried to resolve the controversies related to its use. The concerns over an increase in cardiovascular complications and mortality following nitrous oxide use have been negated by recent data. However, its use in certain vulnerable populations like children with cobalamin and folate deficiency or defects in their metabolic pathways remains a cause of concern for its toxic effects. In this narrative review, we aim to discuss the pharmacological properties of nitrous oxide, the potential advantages and drawbacks of the use of nitrous oxide in children, address the neurodevelopmental and other systemic effects, and throw light on the evidence regarding the safety of nitrous oxide use and its current role in pediatric procedural sedation and anesthesia practice. The literature related to its use in the pediatric population for painful procedures and surgeries has been summarized.

Success rate of nitrous oxide-oxygen procedural sedation in dental patients: systematic review and meta-analysis

The aim of this systematic review was to determine the success rate of nitrous oxide-oxygen procedural sedation (NOIS) in dentistry. A systematic digital search was conducted for publications or reports of randomized controlled trials evaluating the clinical performance of NOIS. Abstracts of research papers were screened for suitability, and full-text articles were obtained for those who met the inclusion and exclusion criteria accordingly. The quality of the studies was assessed using the revised Cochrane risk-of-bias tool (RoB 2). A total of 19 articles (eight randomized clinical trials with parallel intervention groups and 11 crossover trials), published between May 1988 and August 2019, were finally selected for this review. The studies followed 1293 patients reporting NOIS success rates, with a cumulative mean value of 94.9% (95% CI: 88.8–98.9%). Thirteen trials were conducted on pediatric populations (1098 patients), and the remaining six were conducted on adults (195 patients), with cumulative efficacy rates of 91.9% (95% CI: 82.5–98.1%) and 99.9% (95% CI: 97.7–100.0%), respectively. The difference was statistically significant (P = 0.002). Completion of treatment and Section IV of the Houpt scale were the most used efficacy criteria. Within the limitations of this systematic review, the present study provides important information on the efficacy rate of NOIS. However, further well-designed and well-documented clinical trials are required and there is a need to develop guidelines for standardization of criteria and definition of success in procedural sedation. Currently, completion of treatment is the most used parameter in clinical practice, though many others also do exist at the same time. To maximize NOIS efficacy, clinicians should strictly consider appropriate indications for the procedure.

Understanding the Effects of Anesthesia on Cortical Electrophysiological Recordings: A Scoping Review

General anesthesia in animal experiments is an ethical must and is required for all the procedures that are likely to cause more than slight or momentary pain. As anesthetics are known to deeply affect experimental findings, including electrophysiological recordings of brain activity, understanding their mechanism of action is of paramount importance. It is widely recognized that the depth and type of anesthesia introduce significant bias in electrophysiological measurements by affecting the shape of both spontaneous and evoked signals, e.g., modifying their latency and relative amplitude. Therefore, for a given experimental protocol, it is relevant to identify the appropriate anesthetic, to minimize the impact on neuronal circuits and related signals under investigation. This review focuses on the effect of different anesthetics on cortical electrical recordings, examining their molecular mechanisms of action, their influence on neuronal microcircuits and, consequently, their impact on cortical measurements.

Neuropsychopharmacological effects of midazolam on the human brain

As a commonly used anesthetic agent, midazolam has the properties of water-soluble, rapid onset, and short duration of action. With the rapid development in the field of neuroimaging, numerous studies have investigated how midazolam acts on the human brain to induce the alteration of consciousness. However, the neural bases of midazolam-induced sedation or anesthesia remain beginning to be understood in detail. In this review, we summarize findings from neuroimaging studies that have used midazolam to study altered consciousness at different levels and content. We also compare the results to those of neuroimaging studies using diverse anesthetic agents and describe the common neural correlates of anesthetic-induced alteration of consciousness.

Conscious sedation service for geriatric and special-care dentistry: A health policy brief

Background:

Geriatric and special care dentistry (GSD) involves oral health care for seniors and individuals with disabilities. Due to ethical issues, finances, waiting times, treatment versatility and so on, conscious sedation (CS) may have a place to optimise the delivery of care.

Objectives:

This article identifies considerations for implementing CS in GSD services in Singapore.

Methods:

Taking the form of a health policy brief, this review (a) defines the situation for patients with special-care needs and justified the need for dental CS, (b) makes reference to practices from countries with established dental CS services, (c) states and evaluates available CS techniques for the GSD centre in Singapore and (d) discusses action plans and considerations for implementation.

Results:

Demographic analysis revealed that 23.8% of the GSD patients could have benefitted from CS, or 44.7% of all patients who required behavioural management. The key advantages of CS included enhanced safety, more teeth saved and a reduction in general anaesthesia wait, amongst others. Conventional dental CS techniques included midazolam via various routes, nitrous oxide and ketamine. To establish a CS service, key points of consideration need to be conceptualised first, such as adequate training, perception of patients and providers, operational costs, facilities and developing guidance specific for oral health professionals.

Conclusion:

A local CS service will be beneficial for GSD patients in view of the challenges faced. A group of experts and stakeholders is needed to provide practical consensus.