Comparison of Intubated Versus Nonintubated Airway Management in Children Under General Anesthesia Provided by Dentist Anesthesiologists

Purpose: Use of general anesthesia (GA) for comprehensive dental treatment of children is an essential health benefit. Pediatric dentists utilize dentist anesthesiologists to provide GA for dental rehabilitation of severe early childhood caries. Dentist anesthesiologists deliver GA using intubated or nonintubated GA. The purpose of this study was to compare the incidence of respiratory complications when intubated versus nonintubated general anesthesia was completed by dentist anesthesiologists in a pediatric dentistry setting. Methods: The Society of Ambulatory Anesthesia (SAMBA) Clinical Outcomes Registry (SCOR) database was queried for pediatric dental GA cases completed by dentist anesthesiologists from January 1, 2010 to December 31, 2016. Logistic regression compared intubated GA versus nonintubated GA for differences in the incidence of respiratory complications. Results: Within 9,333 cases, there were 30 incidents of laryngospasm (0.3 percent), 19 incidents of bronchospasm (0.2 percent), two incidents of hypoxia (less than 0.1 percent), and six incidents of difficult airway (0.1 percent). When intubated versus nonintubated GA was compared for respiratory complication incidence, no significant association was found (P=0.81, odds ratio equals 0.93). Conclusion: No significant difference was found between the incidence of respiratory complications with intubated versus nonintubated GA provided by dentist anesthesiologists.

Adverse Events During Dental Care for Children: Implications for Practitioner Health and Wellness

Adverse events during dental care for children inevitably happen, despite precautionary procedures. Remedial measures have primarily focused upon affected children and their parents/caregivers. The purpose of this paper was to summarize the effects of adverse events upon practitioners involved in the incident who have been termed second victims. Affected practitioners may suffer negative emotions impinging upon their professional performance as well as deleterious personal health consequences, including substance abuse and depression/suicidal ideation. Peer support has been identified as an important mechanism to foster recovery in second victims. Practitioners need supportive efforts following their inadvertent involvement in adverse events to facilitate their recovery and maintenance of personal health and wellness.

Procedural pain in routine dental care for children: a part of the Swedish BITA study

AIM

To investigate the frequency and reported intensity levels of dental treatment pain and discomfort in children, in conjunction with regular dental visits.

METHODS

The study included 2363 children in four different age cohorts. Data was collected from structured interviews by dental personnel regarding pain experiences or discomfort after treatments, including analgesia, extractions, operative treatments and radiographic examinations.

RESULTS

One-third of all treatment occasions were experienced as painful and/or causing discomfort. Treatment sessions including analgesia were assessed as painful in 49.7% of occasions, with injection being the most common given reason for pain. Extraction was painful in 62.4% of occasions, with injection as the main reason for pain. Operative treatments were assessed as painful in 38.8% of occasions, with drilling as the most common reason for pain and discomfort. Pain was reported in approximately 19% of all radiographic examinations.

CONCLUSIONS

Injection was the major reason for pain during treatment, including injection and extraction, while drilling was the most common cause of pain during restorative treatment. Dentists should try to minimise the experience of pain and discomfort by using all available measures to perform pain-free and effective dental injections.

Middle East respiratory syndrome in children. Dental considerations

As of January 2016, 1,633 laboratory-confirmed cases of Middle East Respiratory Syndrome Coronavirus (MERS-CoV) infection and 587 MERS-related deaths have been reported by the World Health Organization globally. Middle East Respiratory Syndrome Coronavirus may occur sporadically in communities or may be transmitted within families or hospitals. The number of confirmed MERS-CoV cases among healthcare workers has been increasing. Middle East Respiratory Syndrome Coronavirus may also spread through aerosols generated during various dental treatments, resulting in transmission between patients and dentists. As MERS-CoV cases have also been reported among children, pediatric dentists are at risk of MERS-CoV infection. This review discusses MERS-CoV infection in children and healthcare workers, especially pediatric dentists, and considerations pertaining to pediatric dentistry. Although no cases of MERS-CoV transmission between a patient and a dentist have yet been reported, the risk of MERS-CoV transmission from an infected patient may be high due to the unique work environment of dentists (aerosol generation).

Orbital, Mediastinal and Cervicofacial Subcutaneous Emphysema after Dental Rehabilitation in a Pediatric Patient

Subcutaneous emphysema is a rare possible complication of dental procedures. The majority of the dental literature describes cases of localized areas of subcutaneous emphysema following various dental procedures, with a large number of these cases seen following intraoral surgical procedures. Classically, subcutaneous emphysema occurs within minutes to hours after conclusion of dental procedures and is commonly misdiagnosed as either an allergic reaction or acute post-operative swelling. This case report describes a four-year-old male who underwent dental rehabilitation for routine restorative dentistry without extractions under general anesthesia. He subsequently developed extensive subcutaneous emphysema involving the right periorbital region, cervicofacial spaces, and caudal extension to include the superior aspect of the mediastinum. The purpose of this report was to provide a brief review of the prior literature on the subject, report on the case, and review the management for patients with subcutaneous emphysema.

Preoperative analgesics for additional pain relief in children and adolescents having dental treatment

BACKGROUND

Fear of dental pain is a major barrier to treatment for children who need dental care. The use of preoperative analgesics has the potential to reduce postoperative discomfort and intraoperative pain. We reviewed the available evidence to determine whether further research is warranted and to inform the development of prescribing guidelines. This is an update of a Cochrane review published in 2012.

OBJECTIVES

To assess the effects of preoperative analgesics for intraoperative or postoperative pain relief (or both) in children and adolescents undergoing dental treatment without general anaesthesia or sedation.

SEARCH METHODS

We searched the following electronic databases: Cochrane Oral Health's Trials Register (to 5 January 2016), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library 2015, Issue 12), MEDLINE via OVID (1946 to 5 January 2016), EMBASE via OVID (1980 to 5 January 2016), LILACS via BIREME (1982 to 5 January 2016) and the ISI Web of Science (1945 to 5 January 2016). We searched ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform for ongoing trials to 5 January 2016. There were no restrictions regarding language or date of publication in the searches of the electronic databases. We handsearched several specialist journals dating from 2000 to 2011.We checked the reference lists of all eligible trials for additional studies. We contacted specialists in the field for any unpublished data.

SELECTION CRITERIA

Randomised controlled clinical trials of analgesics given before dental treatment versus placebo or no analgesics in children and adolescents up to 17 years of age. We excluded children and adolescents having dental treatment under sedation (including nitrous oxide/oxygen) or general anaesthesia.

DATA COLLECTION AND ANALYSIS

Two review authors assessed titles and abstracts of the articles obtained from the searches for eligibility, undertook data extraction and assessed the risk of bias in the included studies. We assessed the quality of the evidence using GRADE criteria.

MAIN RESULTS

We included five trials in the review, with 190 participants in total. We did not identify any new studies for inclusion from the updated search in January 2016.Three trials were related to dental treatment, i.e. restorative and extraction treatments; two trials related to orthodontic treatment. We did not judge any of the included trials to be at low risk of bias.Three of the included trials compared paracetamol with placebo, only two of which provided data for analysis (presence or absence of parent-reported postoperative pain behaviour). Meta-analysis of the two trials gave arisk ratio (RR) for postoperative pain of 0.81 (95% confidence interval (CI) 0.53 to 1.22; two trials, 100 participants; P = 0.31), which showed no evidence of a benefit in taking paracetamol preoperatively (52% reporting pain in the placebo group versus 42% in the paracetamol group). One of these trials was at unclear risk of bias, and the other was at high risk. The quality of the evidence is low. One study did not have any adverse events; the other two trials did not mention adverse events.Four of the included trials compared ibuprofen with placebo. Three of these trials provided useable data. One trial reported no statistical difference in postoperative pain experienced by the ibuprofen group and the control group for children undergoing dental treatment. We pooled the data from the other two trials, which included participants who were having orthodontic separator replacement without a general anaesthetic, to determine the effect of preoperative ibuprofen on the severity of postoperative pain. There was a statistically significant mean difference in severity of postoperative pain of -13.44 (95% CI -23.01 to -3.88; two trials, 85 participants; P = 0.006) on a visual analogue scale (0 to 100), which indicated a probable benefit for preoperative ibuprofen before this orthodontic procedure. However, both trials were at high risk of bias. The quality of the evidence is low. Only one of the trials reported adverse events (one participant from the ibuprofen group and one from the placebo group reporting a lip or cheek biting injury).

AUTHORS' CONCLUSIONS

From the available evidence, we cannot determine whether or not preoperative analgesics are of benefit in paediatric dentistry for procedures under local anaesthetic. There is probably a benefit in using preoperative analgesics prior to orthodontic separator placement. The quality of the evidence is low. Further randomised clinical trials should be completed with appropriate sample sizes and well defined outcome measures.

Preformed crowns for decayed primary molar teeth

BACKGROUND

Crowns for primary molars are preformed and come in a variety of sizes and materials to be placed over decayed or developmentally defective teeth. They can be made completely of stainless steel (know as 'preformed metal crowns' or PMCs), or to give better aesthetics, may be made of stainless steel with a white veneer cover or made wholly of a white ceramic material. In most cases, teeth are trimmed for the crowns to be fitted conventionally using a local anaesthetic. However, in the case of the Hall Technique, PMCs are pushed over the tooth with no local anaesthetic, carious tissue removal or tooth preparation. Crowns are recommended for restoring primary molar teeth that have had a pulp treatment, are very decayed or are badly broken down. However, few dental practitioners use them in clinical practice. This review updates the original review published in 2007.

OBJECTIVES

Primary objectiveTo evaluate the clinical effectiveness and safety of all types of preformed crowns for restoring primary teeth compared with conventional filling materials (such as amalgam, composite, glass ionomer, resin modified glass ionomer and compomers), other types of crowns or methods of crown placement, non-restorative caries treatment or no treatment. Secondary objectiveTo explore whether the extent of decay has an effect on the clinical outcome of primary teeth restored with all types of preformed crowns compared with those restored with conventional filling materials.

SEARCH METHODS

We searched the following electronic databases: Cochrane Oral Health Group Trials Register (to 21 January 2015), Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library, 2014, Issue 12), MEDLINE via Ovid (1946 to 21 January 2015) and EMBASE via Ovid (1980 to 21 January 2015). We searched the US National Institutes of Health Trials Register (http://clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform for ongoing trials and Open Grey for grey literature (to 21 January 2015). No restrictions were placed on the language or date of publication when searching the databases.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that assessed the effectiveness of crowns compared with fillings, other types of crowns, non-restorative approaches or no treatment in children with untreated tooth decay in one or more primary molar teeth. We would also have included trials comparing different methods of fitting crowns.For trials to be considered for this review, the success or failure of the interventions and other clinical outcomes had to be reported at least six months after intervention (with the exception of 'pain/discomfort during treatment and immediately postoperatively').

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the title and abstracts for each article from the search results. and independently assessed the full text for each potentially relevant study. At least two authors assessed risk of bias and extracted data using a piloted data extraction form.

MAIN RESULTS

We included five studies that evaluated three comparisons. Four studies compared crowns with fillings; two of them compared conventional PMCs with open sandwich restorations, and two compared PMCs fitted using the Hall Technique with fillings. One of these studies included a third arm, which allowed the comparison of PMCs (fitted using the Hall Technique) versus non-restorative caries treatment. In the two studies using crowns fitted using the conventional method, all teeth had undergone pulpotomy prior to the crown being placed. The final study compared two different types of crowns: PMCs versus aesthetic stainless steel crowns with white veneers. No RCT evidence was found that compared different methods of fitting preformed metal crowns (i.e. Hall Technique versus conventional technique).We considered outcomes reported at the dental appointment or within 24 hours of it, and in the short term (less than 12 months) or long term (12 months or more). Some of our outcomes of interest were not measured in the studies: time to restoration failure or retreatment, patient satisfaction and costs. Crowns versus fillingsAll studies in this comparison used PMCs. One study reported outcomes in the short term and found no reports of major failure or pain in either group. There was moderate quality evidence that the risk of major failure was lower in the crowns group in the long term (risk ratio (RR) 0.18, 95% confidence interval (CI) 0.06 to 0.56; 346 teeth in three studies, one conventional and two using Hall Technique). Similarly, there was moderate quality evidence that the risk of pain was lower in the long term for the crown group (RR 0.15, 95% CI 0.04 to 0.67; 312 teeth in two studies).Discomfort associated with the procedure was lower for crowns fitted using the Hall Technique than for fillings (RR 0.56, 95% CI 0.36 to 0.87; 381 teeth) (moderate quality evidence).It is uncertain whether there is a clinically important difference in the risk of gingival bleeding when using crowns rather than fillings, either in the short term (RR 1.69, 95% CI 0.61 to 4.66; 226 teeth) or long term (RR 1.74, 95% CI 0.99 to 3.06; 195 teeth, two studies using PMCs with conventional technique at 12 months) (low quality evidence). Crowns versus non-restorative caries treatmentOnly one study compared PMCs (fitted with the Hall Technique) with non-restorative caries treatment; the evidence quality was very low and we are therefore we are uncertain about the estimates. Metal crowns versus aesthetic crownsOne split-mouth study (11 participants) compared PMCs versus aesthetic crowns (stainless steel with white veneers). It provided very low quality evidence so no conclusions could be drawn.

AUTHORS' CONCLUSIONS

Crowns placed on primary molar teeth with carious lesions, or following pulp treatment, are likely to reduce the risk of major failure or pain in the long term compared to fillings. Crowns fitted using the Hall Technique may reduce discomfort at the time of treatment compared to fillings. The amount and quality of evidence for crowns compared to non-restorative caries, and for metal compared with aesthetic crowns, is very low. There are no RCTs comparing crowns fitted conventionally versus using the Hall Technique.

Local anesthetic calculations: avoiding trouble with pediatric patients

Local anesthetic systemic toxicity (LAST) is a rare but avoidable consequence of local anesthetic overdose. This article will review the mechanism of action of local anesthetic toxicity and the signs and symptoms of LAST. Due to physiologic and anatomic differences between children and adults, LAST occurs more frequently in children; particularly when 3% mepivacaine is administered. The calculation of the maximum recommended dose based on mg/lb body weight, Clark's rule, and the Rule of 25 in order to prevent LAST will also be reviewed, as well as the appropriate treatment procedures for a local anesthetic overdose.

[Dental treatment in children with dystrophic form of epidermolysis bullosa]

The aim of the study was to summarize the experience for providing oral health care in children with epidermolysis bullosa (EB) treated in Central Research Institute of Dentistry and Maxillofacial Surgery in 2013-2014. Seven EB patients (5 female and 2 male aged 5-17) with dystrophic form of EB were included in the study. Oral status was recorded (oral hygiene, presence of enamel hypoplasia and intraoral soft tissue lesions). Dental treatment provided included teeth extractions under conscious sedation (6 cases), teeth treatment (both conventional and ART methods) (5 cases) and preventive program (5 cases). All 7 dystrophic EB patients presented with generalized enamel hypoplasia in both primary and permanent dentition. In these patients one should consider using non-adhesive face dressings and careful suction pipe positioning as well as applying liniments on cotton rolls not to cause both intraoral and extraoral soft tissue lesions. Sixteen milk teeth were extracted under conscious sedation, in 3 cases the procedure caused significant vestibular scarring. Twelve teeth were treated mostly by ART method (n=1 0) as limited mouth opening made conventional treatment impossible. Dental treatment in dystrophic EB is a real challenge for pediatric dentist. This group of patients requires a special dental rehabilitation plan as they present with generalized enamel hypoplasia and have significant risk of intraoral lesions.

Parental attitudes and experiences of dental care in children and adolescents with ADHD--a questionnaire study

Attention deficit hyperactivity disorder (ADHD) is a common psychiatric condition characterized by age-inappropriate levels of inattention, hyperactivity-impulsiveness or a combination of these. The aim of this study was to analyze parental attitudes to and experience of dental care, oral hygiene and dietary habits in children/adolescents with ADHD. Twenty- six parents of 31 subjects, 20 boys and 11 girls, aged 5-19 years with ADHD registered at the Gothenburg Child Neuropsychiatric Clinic, were invited. The parents answered a questionnaire regarding different oral problems when visiting the Clinic of Pediatric Dentistry, Gothenburg, for an oral examination of their child. The parents felt the dental care at the Public Dental Service was good, but noted a lack of knowledge regarding child neuropsychiatry among the dental staff which may influence the dental treatment. Fifteen parents reported their children had experienced mouth pain and 15 reported their child had suffered from both discomfort and pain from local anesthesia. Thirteen of the children had a dental trauma and 12 parents reported pain in connection to the dental treatment. Pain related to filling therapy was stated by 11 parents. According to the parents, five children suffered from dental fear but 15 reported the child had a general fear. Pursuant to the parents, the beverage for dinner was mainly milk or water, while sweet drinks were more frequent when thirsty. Seventeen parents reported their children had poor oral hygiene or could not manage to brush their teeth and 14 of the 31 children only brushed once a day or less. The results show that the parents experience a lack of child neuropsychiatric knowledge, care and patience from the dental staff, which may influence the treatment. Oral hygiene/tooth brushing is neglected and the frequent consumption of sugar is difficult for the parents to handle.

Post-operative pain and anxiety related to dental procedures in children

AIM

To determine post-operative pain in children following treatment in the dental chair and its relation to dental anxiety.

METHODS

A group of 125 children, aged 5 to 18 years, attending for dental treatment had their pain recorded post-operatively using the revised version of the Faces Pain Scale (FPS-R) and the Visual Analogue Scale (VAS). Baseline anxiety scores were also recorded using the Modified Child Dental Anxiety Scale (faces) (MCDASf).

RESULTS

The mean MCDASf score was 20.1. Post-operative pain was reported in 62% of children at 2 hours, 51% at 4, and 47% at 6 hours. The surgical subgroup reported the most pain (79%), whereas the conservative treatment for primary teeth group reported the least pain (37%). Anxious patients (MCDASf > = 17) were more likely to report pain than less anxious patients at 2 (p=0.02) and 6 (p=0.03) hours post-operatively.

CONCLUSION

Dental procedures are associated with post-operative pain in children. Anxious patients are more likely to report pain.

Preoperative analgesics for additional pain relief in children and adolescents having dental treatment

BACKGROUND

Fear of dental pain is a major barrier to children needing dental care. The use of preoperative analgesics has the potential to reduce postoperative discomfort. In addition it might also reduce intraoperative pain. Reviewing the available evidence will determine whether further research is warranted and will inform the development of prescribing guidelines.

OBJECTIVES

To assess the effects of preoperative analgesics for pain relief in children and adolescents undergoing dental treatment.

SEARCH METHODS

We searched the following electronic databases: the Cochrane Oral Health Group Trials Register (to 8 March 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 1), MEDLINE via OVID (1950 to 8 March 2012), EMBASE via OVID (1980 to 8 March 2012), LILACS via BIREME (1982 to 8 March 2012) and the ISI Web of Knowledge (1945 to 8 March 2012). There were no restrictions regarding language or date of publication.The reference lists of all eligible trials were checked for additional studies. Specialists in the field were contacted for any unpublished data.

SELECTION CRITERIA

Randomised controlled clinical trials of analgesics given before dental treatment versus placebo or no analgesics in children and adolescents aged up to 17 years. We excluded children and adolescents having dental treatment under sedation (including nitrous oxide/oxygen) or general anaesthesia.

DATA COLLECTION AND ANALYSIS

Two review authors assessed titles and abstracts for eligibility and undertook data extraction and assessment of risk of bias.

MAIN RESULTS

Five trials met the review's inclusion criteria with 190 participants in total. Three trials were dentally related i.e. restorative and extraction treatments; two trials related to orthodontic treatment. None of the included trials were judged to be at low risk of bias. Three trials compared paracetamol with placebo, only two of which provided data for analysis (presence or absence of parent-reported postoperative pain behaviour). The meta-analysis of the two trials showed a nonsignificant risk ratio (RR) for postoperative pain-related behaviours of 0.81 (95% confidence interval (CI) 0.53 to 1.22; P = 0.31), which showed no evidence of a benefit in taking paracetamol preoperatively (52% reporting pain in placebo versus 42% in test group). One of these trials was at unclear risk of bias, the other at high risk. Four trials compared ibuprofen with placebo. Three of these trials provided useable data. One trial reported no statistical difference in postoperative pain experienced by the ibuprofen group and the control group for children undergoing dental treatment. Data from two trials, including patients who were having orthodontic separator replacement without a general anaesthetic, were pooled to determine the effect of preoperative ibuprofen on the severity of postoperative pain. There was a statistically significant benefit, with regard to severity of postoperative pain, for giving ibuprofen preoperatively with mean difference -19.12 (95% CI -29.36 to -8.87; P = 0.0003; moderate quality evidence) on a visual analogue scale (0 to 100) indicating a probable benefit for preoperative ibuprofen before this orthodontic procedure. However, both these trials were at high risk of bias. Adverse events were only reported in one trial (one patient from the ibuprofen group and one from the placebo group reporting a lip or cheek biting injury).

AUTHORS' CONCLUSIONS

From the available evidence we cannot determine whether or not preoperative analgesics are of benefit in paediatric dentistry for procedures under local anaesthetic. There is probably a benefit in prescribing preoperative analgesics prior to orthodontic separator placement.

An investigation of language used by children to describe discomfort expected and experienced during dental treatment

OBJECTIVES

A study of dental pulp testing has shown that children's linguistic comprehension and chronological age independently influence their descriptions of pain. The present study sought first to demonstrate this for expectations and experience of routine dental treatment, and secondly, to determine whether the effect of age was the result of previous dental and medical experience.

SAMPLE

Forty-six children between 6 and 17 years of age attending two paediatric dental clinics for routine invasive procedures comprised the study sample.

METHODS

To describe their expectations of forthcoming treatment, each child selected words from a published list, and gave ratings on scales describing the degree of severity as 'sore' or 'tingly'. They also completed the Child Dental Anxiety Scale and the Spielberger State-Trait Anxiety Scale for Children. After treatment, they described the treatment with the same list and scales, then completed the British Picture Vocabulary Scale and a dental-medical history questionnaire.

RESULTS

The children, especially the most anxious ones, chose more words from the list for their expectations than for their experience of treatment, suggesting, as in previous studies, that they expected more discomfort than they experienced. Ratings of 'sore' and 'tingly' did not show this discrepancy. For both expectations and experience of treatment, the children with the largest vocabularies chose the fewest words, thus being more discriminating in their choices. However, vocabulary had no effect on ratings of 'sore' and 'tingly'. There were no significant relationships among age, estimates of discomfort and medical-dental histories.

CONCLUSIONS

The results suggest that a list of adjectives provides the most discriminating measure of discomfort. They also show that it is necessary to take into account children's linguistic development to evaluate their estimates of pain so as not to entertain the belief of many clinicians that children exaggerate such reports.

Danish dentists' knowledge, attitudes and management of procedural dental pain in children: association with demographic characteristics, structural factors, perceived stress during the administration of local analgesia and their tolerance towards pain

OBJECTIVE

The aim of the present study was to describe Danish dentists' knowledge of, attitudes towards and management of procedural pain during paediatric dental care, and to assess the importance of demographic characteristics, structural factors, perceived stress during administration of local analgesia and the dentists' own tolerance towards procedural dental pain.

DESIGN

A cross-sectional questionnaire study was conducted in Denmark in May 2001.

SUBJECTS AND METHODS

The subjects were a random sample of 30% of Danish dentists treating children. Usable information was obtained from 327 (80.3%) of the dentists in the sample.

RESULTS

One-quarter of the respondents answered that a 3-5-year-old child could report pain only with uncertainty. More than 80% of the dentists stated that they never compromised on painlessness. Very few agreed to the statement that children forget pain faster than adults. One-third agreed to, or were neutral to, the statement that all restorative care in primary teeth could be performed painlessly using N2O-O2 sedation alone. The majority of the respondents reported using three or more methods to assess the effect of their pain control methods. Almost 90% reported using local analgesia for restorative work 'always' or 'often'. A similar proportion reported using topical analgesia before injection 'always' or 'often'. Administering a mandibular block to preschool children was the procedure perceived as the most stressful (33.6%) pain control method. Demographic factors (gender), structural factors (always working alone and treating 3-5-year-old children daily), perceived stress during the administration of a mandibular block in preschool children and the dentists' own willingness to accept potentially painful dental treatment without local analgesia were associated with knowledge of, attitudes towards and management of procedural dental pain in children.

CONCLUSIONS

Danish dentists treating children demonstrate concern about procedural dental pain in children. Factors amenable to change via training and reorganization into larger clinical units seem to determine their knowledge of, attitudes towards and management of procedural dental pain in children.

[Medical history in relation to dental anxiety in children]

Fear in children is of clearly exogenous origin. Negative experiences will cause fear by direct conditioning. The influence of an important other person can be the root of fear by indirect conditioning. Antecedent factors and intermediary variables associated with fear are described. Usefulness and indications of the different questionnaires for children are specified.

Adverse events and outcomes of conscious sedation for pediatric patients: study of an oral sedation regimen

BACKGROUND

The authors report on adverse events and sedation outcomes for an oral sedation regimen of chloral hydrate, meperidine and hydroxyzine with 100 percent oxygen, or O2, supplementation.

METHODS

In a five-year retrospective study, the authors examined 195 records of conscious sedation performed in 111 healthy children aged 24 to 48 months (mean, 47 months). The authors analyzed age, sex, weight, methods of drug delivery, waiting time after drug administration, treatment rendered, treatment time, adverse events, sedation outcomes and the number of visits needed to complete treatment using descriptive statistics, chi 2 tests, t test and analysis of variance.

RESULTS

Adverse events--including vomiting, desaturation, prolonged sedation and an apneic event--occurred in 3 percent of all sedations and were minor. Seventy-two percent of sedations had satisfactory behavioral outcomes, 23 percent had unsatisfactory outcomes, and 5 percent of the cases were aborted because of disruptive behavior. Sex was not a significant factor for the success. Patient compliance with drinking medications (P = .013) and a longer waiting time after medication intake (P = .012) yielded better sedation outcomes.

CONCLUSIONS

Minimal minor adverse events occurred with this sedation regimen. The success rate was 72 percent. Compliance with taking oral medications and waiting time appeared to be important factors in predicting sedation success.

CLINICAL IMPLICATIONS

This oral sedation regimen offers reasonable outcomes with minimal adverse events under a strict protocol and use of O2 supplementation. The results also revealed associations that give guidance for case selection and outcome prediction.

The appropriate use of physical restraint: considerations

Many people with severe and profound mental retardation have poor oral health and suffer from inadequate oral hygiene. They may also have neurological disorders and limited intellect, which can erect barriers to dental treatment, such as resistive behavior. Lack of an agreed-upon definition of physical restraint by clinicians or governmental and administrative nondental professionals adds to the problem. As a result, controversy and confusion arise when the appropriate use of safety support systems, (i.e., physical restraint) is considered. The purpose of this paper is to address the need for and appropriate use of restraint for a specific population and set of conditions. The appropriate use of restraint permits the administration of oral hygiene, which can help control the level of oral health in this population; if restraint is not used, oral hygiene cannot be accomplished, dental disease increases, and dental neglect can be cited. This paper concludes with several sets of restraint guidelines for appropriate use.

A comparison of post-operative morbidity following outpatient dental care under general anaesthesia in paediatric patients with and without disabilities

An investigation was undertaken of morbidity after outpatient general anaesthesia for comprehensive dental care in a group of paediatric patients over a 1-year period. Data were collated from the patient's hospital notes and from the response to a questionnaire sent to parents/carers. Clinical data were obtained for 55 cases (age range 3-17 years) for whom parents/carers had returned questionnaires. There were 27 intellectually and/or physically impaired patients, the other 28 being anxious or phobic. After discharge, 44% of all parents/carers reported symptoms post-operatively in their child, the prevalence being similar in both groups. The symptoms were nausea/vomiting (20%), unexpected drowsiness (13%) and the need for pain relief at home (13%). Dental procedures were routine restorations (42%), or a combination of restoration, extractions and preventive care for the remainder. Only four patients had extractions only. One teenager had to be admitted for persistent nausea and vomiting, despite prophylactic measures. In conclusion, post-operative morbidity appears to be low after outpatient general anaesthesia for dental procedures, and is no greater in patients with disabilities.

Odontogenic bacteremia following tooth cleaning procedures in children

PURPOSE

This study was designed to investigate the prevalence and intensity of odontogenic bacteremia from tooth cleaning procedures in children and adolescents.

METHODS

One hundred and fifty five children receiving dental treatment under general anesthesia at The Great Ormond Street Hospital for Children and Guy's Hospital were recruited. Each child was randomly allocated to one of three tooth cleaning groups. These were (1) toothbrushing, (2) professional cleaning with a rubber cup and (3) scaling.

RESULTS

There was no significant difference in the prevalence of positive blood cultures or intensity of bacteremia between the three groups. The bacterial species isolated were similar to those reported by other workers. These were S. mitis, S. sanguis and Coagulase--negative staphylococci, all of which are implicated in the pathogenesis of Bacterial Endocarditis.

CONCLUSIONS

Patients at risk are as likely to develop odontogenic bacteremia from toothbrushing at home as from professional scaling and polishing of the teeth at dental surgery.

Effect of nitrous oxide-oxygen inhalation with scavenging on behavioral and physiological parameters during routine pediatric dental treatment

PURPOSE

The purpose of this study was to determine the influence of 40% nitrous oxide/60% oxygen inhalation with scavenging on the behavioral and physiological parameters during routine pediatric dental procedures.

METHODS

Twenty-two subjects, aged 60-116 months, were randomized into a double blind, cross-over study design and administered alternately either 40% nitrous oxide/60% oxygen or 100% oxygen during two sequential restorative appointments. All subjects were monitored continuously for respiratory rate, pulse rate, and hemoglobin oxygen saturation using a combined capnograph and pulse oximeter. The subject's breath sound and behavior were recorded every minute along with vital signs.

RESULTS

When compared to 100% oxygen inhalation, 40% nitrous oxide/60% oxygen inhalation produced significant reductions in adverse patient behavior, respiratory rate, and pulse rate, but did not affect percent hemoglobin oxygen saturation. Nitrous oxide inhalation had no effect on breath sound revealed by auscultation or on the occurrence of the apnea alarm displayed by the capnograph.

CONCLUSIONS

This study demonstrated that the administration of 40% nitrous oxide/60% oxygen delivered via a scavenging nasal hood significantly improved patient behavior and altered physiological parameters commonly monitored during conscious sedation.

Comparison of the use of a child and an adult dentifrice by a sample of preschool children

The purpose of this study was to compare the use of a child dentifrice (CD) and an adult dentifrice (AD) by a convenience sample of preschool-aged children. Fifty participants, ages 31 to 60 months, were recruited from a dental school clinic and an area day care center. All were healthy, free of developmental delays, and capable of applying dentifrice to a toothbrush. The study employed a crossover design in which the children each brushed their teeth twice, once with each type of dentifrice. The order of dentifrice use was assigned randomly, and the two brushings were separated by at least 1 week. The following were recorded: 1) the amount of dentifrice applied, 2) the time spent brushing, and 3) whether the child expectorated and/or rinsed after brushing. The mean weight of CD the children used (0.689 g, 0.43 SD) was significantly greater than that of AD (0.509 g, 0.41 SD, P = 0.02, Wilcoxon's signed rank test). The mean time spent brushing with CD (83.56 sec, 85.4 SD) was significantly greater than for AD (57.48 sec, 39.0 SD, P = 0.01). A "risk factor" (dentifrice weight x usage time) was derived to estimate the relative fluoride exposure of each child. The mean risk factor for CD (58.54, 64.8 SD) was significantly greater than that for AD (27.43, 25.0 SD, P < 0.001). Most children did not expectorate or rinse after brushing. Most parents selected drawings on a questionnaire that indicated that their child routinely used 0.25-0.5 g of dentifrice per brushing, which underestimated the amount they used in the study. The results of this study indicated that young children may be exposed to more fluoride for a longer period of time with CD.

Dental bacteremia in children

Bacteremia resulting from dental extraction is regarded as an important cause of bacterial endocarditis, and it is therefore recommended that patients undergoing tooth extraction be given prophylactic antibiotics. As dental procedures other than extractions may also cause bacteremias, we studied a variety of dental procedures routinely used in pediatric dentistry. Blood samples for cultures were obtained 30 s after each of 13 dental operative procedures in 735 anesthetized children aged 2-16 years. Four procedures used for conservative dentistry caused bacteremias significantly more often than the baseline value of 9.4%: polishing teeth 24.5%, intraligamental injection 96.6%, rubber dam placement 29.4%, and matrix band with wedge placement 32.1%. In comparison, toothbrushing alone caused a bacteremia on 38.5% of occasions. The organisms isolated were typical of odontogenic bacteremias in that 50% of the isolates were identified as varieties of viridans streptococci. These data show that a wider variety of dental procedures than was previously documented cause bacteremia.

Medical complications following successful pediatric dental treatment

Dental treatment is usually performed without any development of medical sequela. However, patients can acquire serious, life threatening complications, even though successful dental treatment is completed. This paper presents four case reports of medical complications following routine pediatric dental treatment. The cases include: Ludwig's angina, endocarditis, brain abscess, and anesthetic toxicity. Many of the medical complications were caused by pre-existing conditions and were not necessarily direct result of dental treatment. Although medical complications following dental treatment cause grave concern, the dental practitioner can learn much from these occurrences.

Facial nerve paralysis of dental origin in children

Dental causes of facial nerve paralysis are rare and have not been previously reported in children. Two children are described with facial nerve paralysis of dental origin. The underlying mechanism of action and pathogenesis are discussed.