Wednesday, February 29, 2012

Use of Restraint and Management Style as Parameters for Defining Sedation Success: A Survey of Pediatric Dentists

Authors: Kaaren G. Vargas, DDS, PhD, John E. Nathan, DDS, MDS, Fang Qian, PhD, and Ari Kupietzky DMD, MSc
Journal: Pediatric Dentistry, V29, No3, May/June 2007
Reviewed by: Fotini M. Dionisopoulos

Purpose: To recognize factors that may influence the current AAPD members' definitions of a successful oral sedation.

Methods:


  • A letter was electronically mailed to all AAPD members in 2004

  • Surveys were anonymous

  • Questions included: 1) location of practice/institution, 2) type of population served, 3) sedation methods, 4)drug regimens, 5) frequency of sedation, 6) years experience, 7) use of restraint, 8) management style and 9) hypothetical clinical scenarios

Results:



  • The majority of members (55%) characterized their patient management style as authoritarian

  • A large percentage (67%) of dentists answered that employing restraints during sedation does not mean that sedation is inadequate or unacceptable

  • When asked if using restraint during sedation was optimal, there was a smaller percentage (36%)

  • When considering if using restraint during sedation meant that the procedure was successful, the percentage was 47%.

  • Twenty-nine (29%) percent of the practitioners always used restraint with sedation.

  • US dentists were ore likely to always use restraint when using oral sedation.

  • US dentists were more likely to define themselves as authoritarian

  • Respondents who worked in full time private practice were more likely not to prefer to use restraint

Overall, the "take home message"/conclusion of the article was that the practitioner's management style and use of restraint significantly influence how a dentist defines a successful sedation.


Assessment: This is a good article to see the differences in how certain pratitioners may use restraint, or which practioners are more likely use this method during treatment.

A Clinical Study Evaluating Success of 2 Commercially Available Preveneered Primary Molar Stainless Steel Crown

Resident Name: Elliot Chiu

Article Info

Title: A Clinical Study Evaluating Success of 2 Commercially Available Preveneered Primary Molar Stainless Steel Crown

Author: Rona Leith

Journal: Pediatric Dentistry 2011

Main Purpose

-To evaluate the success and parental satisfaction of posterior NuSmile and Kinder Krowns

Methods

­-48 crowns placed on 18 children, each child receiving 2-4 crowns

-Split mouth design, pair matched molars randomly received NuSmiles or Kinder Krowns

-Recall every 3mon for 12mon

Results

-All crowns were retained after 12mon. No significant difference in clinical and radiographic success.

-Both types showed buccal and occlusal facing fracture, occlusal wear, and staining. No significant differences found.

-All parents were satisfied with the esthetics and could not tell a difference between the two.

Key Points

-Esthetic crowns are unable to be crimped and require a passive fit

-Esthetic crowns require more reduction than traditional SSC’s

-Operators did not find any difference in the difficulty placing either crown

-Operators found it difficult to place adjacent esthetic crowns due to the excessive reduction. The author recommends placing a traditional SSC on the 2nd molar and an esthetic crown on the 1st molar.

Assessment

-Very informative article. It would have been great if follow-up times were longer than 1 year and if the esthetic crowns could be compared to traditional SSCs.

Comparison of the Effectiveness of Oral Diazepam and Midazolam for the Sedation of Autistic Patients During Dental Treatment

Resident: Freitas
Article Title: Comparison of the Effectiveness of Oral Diazepam and Midazolam for the Sedation of Autistic Patients During Dental Treatment
Authors: Tanaporn Pisalchaiyong, et al.
Journal: Pediatric Dentistry; 27:3 2005

Purpose:
-The purpose of this study was to compare the effectiveness of oral diazepam and midazolam in sedating autistic patients during dental treatment.

Methods:
-13 subjects aged 5.8 to 14.7 years
-Treatment regimen consisted of nitrous oxide/oxygen inhalation inconjunction with oral administration of either diazepam 0.3 mg/kg or midazolam 0.5mg/kg.
-A drug was classified as being effective when over 70% of the patients taking the drug were judged as “success” in all 3 behavioral criteria: (1) sleeping; (2) body movement; and (3) crying behaviors.

Results:
-For sleeping behavior, midazolam was found to be significantly more effective than diazepam as the duration of stimulation increased.
-For the movement and crying behaviors, midazolam also proved to be significantly more effective from the start of treatment through the 35- and 40-min markers. For the remainder of treatment, there was no significant difference between the two drugs.
-In this study, Diazepam and midazolam were rated as 77% and 100% successful, according to the overall behavior evaluation criteria.

Discussion:
-Both diazepam and midazolam were shown to be effective sedative agents,successfully and safely used to sedate autistic patients for dental treatment.
-Midazolamwas significantly more effective than diazepam in those portions of the procedure withincreased stimulation.

Assessment:
-I really enjoyed this article. I wish we had oral sedation as an option for treating some of our autistic patients who we believe would benefit. Any progress made during each dental treatment is a huge milestone for most of our autistic patients, but I'm sure we all wish we could do even more to help our patients and oral sedation may be a good option.

A Survey Study of Sedation Training in Advanced Pediatric Dentistry Programs: Thoughts of Program Directors and Students

Kyung-Hong Cal Kim

A Survey Study of Sedation Training in Advanced Pediatric Dentistry Programs: Thoughts of Program Directors and Students

Authors: Wilson S, Nathan JE

Pediatric Dentistry V33/No.4 Jul/Aug 11

Purpose:
To survey program directors (PD) and students of advanced pediatric dentistry training programs in the US on sedation issues

Methods:
-2 separate surveys targeting 1)program directors (38) and 2)second year residents (74) and those who recently graduated (53)
-Neither group was told of the other’s participation in a survey study

Results:
PDs
-Majority (45%) responded 0-10% when asked about % of time any form of sedation, excluding N2O/O2, was used at their programs by students
-Majority (36%) responded 0 to 5 when asked about number of sedations performed per week in their programs
-Average number of routes used at each institution was 3 (N2O/O2 alone, N2O/O2 + other routes, and Oral route being the top 3 routes used)
-Most frequently used class of sedatives was benzodiazepines, with oral midazolam being the most popular (94% of programs) sedative used
-When asked about rationale behind using N2O/O2 as adjunct to other sedation routes, 100% indicated it is a potentiating agent at the onset, 76% stated N2O/O2 as adjunct when oral agents prove inadequate, and 55% responded it was used for its titratable effects
-When sedations proved inadequate, 68% abandoned the regimen in favor or an alternative modality(GA), 19% selected a different regiment, 3% adjusted the dose of current regimen, and 10% chose different route of administration

Students
-60% indicated they agreed or strongly agreed with the statement of having a strong comfort level in the selection of drugs based on their training.
-50% disagreed or strongly disagreed w/ the statement of having a strong comfort level in the selection and use of various routes of drug administration.
-40% indicated that they agreed or strongly agreed with the statement of having a strong comfort level working in each of minimal, moderate, and deep levels of sedation
-100% felt their training experience w/ inhalation N2O/O2 was either excellent or adequate
-84% felt their training experience w/ oral sedation was excellent or adequate
-90% indicated inadequate experience using the sub-mucosal route, 87% using the IM, 67% intranasal, 70% IV
-Oral midazolam was the most frequently reported drug and route used
-Majority of students indicated they would use sedation more in practice compared to that of their program experiences
-“Avoiding GA” or “getting some treatment completed during visit” were perceived as successful sedation, and restraint is seem as a common and valid intervention during sedation.

-Majority of respondants estimated that 25% or less of the patients required sedation (excluding N2O/O2), and age ranges of children reportedly sedated were primarily between 2 and 9-year-old

Cardiopulomonary parameters assessed using 2 sedation regimens

Resident: Swan
Article Title: Assessment of the Effects of 2 Sedation Regimens on Cardiopulmonary Parameters in Pediatric Dental Patients: A Retrospective Review
Authors: Jung-Wei Chen, et al.
Journal: Pediatric Dentistry; 28:4 2006
Purpose: evaluate cardiopulmonary effects of two sedation regimens: Oral meperidine/hydroxizine/N2O vs oral diazepam/hydroxyzine/submocosal meperidine/N2O.

Background
: Smaller patients often require deeper levels of sedation to successfully complete dental procedures.  Addition of sedative agents such as chloral and meperidine can produce respiratory depression, the most concerning adverse effect in these kids. 

Cote et al found adverse events during conscious sedation to be correlated not with drug class or route of administration, but with these things:
1. drug overdose
2. drug combinations and interactions
3. use of 3 or more sedatives
4. adjunctive use of N2O

In the study, failure of dentist to rescue a sedated patient was either due to
1. a delay in recognizing the severity of the adverse event
2. lack of experience of practitioners in CPR and airway management

Methods:  Retrospective review of 86 sedation records of a single second-year resident. All kids included in study were 1. healthy (ASA I/II) 2. NPO after midnight night before 3. had previously negative documented behavior 4. met AAPD guidelines for sedation. Data collected included 1. O2 saturation 2. blood pressure 3. HR 4. EtCO2 5. Respiratory rate.  Each data point monitored every 5 minutes and printed out afterward. Data were compared using t test and general linear model. All pts given either
Regimen 1: 1 mg/lb meperidine (orally)/25 mg hydroxyzine/N2O 50%
Regimen 2: 5 mg diazepam (crushed)/25 mg hydroxyzine/1 mg/lb meperidine (submucosal)/N2O 50% (only for injection, then shut off)   
*Regimen 2 selected for kids noted to have worse behavior or need more tx

All patients met AAPD discharge criteria before going home; parents asked to sign a sedation discharge form

Results:  62 records. Ave age 4.5. No sig diff in # of sextants treated (~2.8), ave SSCs (~2.2) length of sedation visit (~47 minutes) or time from end of tx to discharge (~13 min).
t test showed sig difference for heart rate, systolic BP/ diastolic BP but not for O2 saturation, RR, EtCO2, MABP..  All values for cardiopulmonary values were WNL.

Discussion: No significant difference when data were compared over time.  Higher RR and BP for Regimen II using t test analysis may be because these kids were selected for worse behavior and may have had more crying, stuggling, movement, etc.

Assessment:  Interesting article. Route of administration didn't result in sig differences, although uptake time was faster for submucosal route.  With that route you also have to give an additional injection and a possible soft tissue reaction at the injection site. I wonder if there would have been any significant differences at all if the pts would have been randomly assigned a drug regimen.

 

 

Allergic Reaction to Inranasal Midazolam HCl: A Case Report

Resident’s Name: Jessica Wilson
Article title: Allergic Reaction to Inranasal Midazolam HCl: A Case Report
Author(s): McIlwain et al.
Journal: Pediatric Dentistry
Year. Volume (number). Page #’s: 2004. 26:4. 359-362.

Background:
Sedative agents used in pediatric dentistry are considered to have a wide safety range, but have been known to cause nausea, vomiting, excessive sleep and allergic reactions. The authors identified only 2 reported cases of midazolam hypersensitivity.

Case Report:
A 5 year old, 23kg male presented with a medical history significant for frequent ear infections, history of RSV and asthma managed with albuterol as needed. Due to behavior management difficulties, oral sedation was planned for the patient. The patient was identified as healthy, NPO and demonstrated normal vitals with no history of allergies or sedations. The parents indicated that the child would not take the medication orally, so 1mL (5mg) of midazolam was administered intranasally via an atomizer.
After 3-4 minutes, the father indicated that the patient’s ankles began to itch. Initial exam revealed urticaria (hives) at both ankles which spread to the lower extremities, stomach, back arms, neck and face within a few minutes. The periorbital skin became edematous, however the patient was alert and in no apparent respiratory distress.
The child would not cooperate for oral diphenhydramine (Benedryl), so the child was transported to the ED where a urticaria allergic reaction was confirmed. 25.0mg diphenhydramine was administered IM, symptoms gradually receded and the child was released after 5 hours with prescriptions of oral Benedryl and prednisone.
Follow-up telephone calls revealed no further complications, although it was uncertain whether or not the parents had success administering the follow-up meds orally at home. Subsequent treatment was completed under chloral hydrate and hydroxyzine with no adverse reactions.

Assessment of Article:
Something to keep in the back of our minds. This article only reinforces that children who receive sedatives in the clinic should be closely monitored from the moment they receive the sedative agent.

Tuesday, February 28, 2012

Obesity: A complicating factor for sedation in children

Resident Name: Sadler
Article Info: Obesity: A complicating factor for sedation in children

Suher Baker

Pediatric Dentistry 29:6; 2006

Main Purpose: Review of literature and protocols associated with sedation of overweight children

Key Points:

· Currently 27% of adults and 50% of children are classified as overweight. 300,000 premature deaths and $100 billion in healthcare costs.

· While sedation becomes more commonplace with pediatric patients the procedures have continued to become more safe. Current estimates put the mortality rate at 1:250,000. Most common major complications arise from hypoxia.

· Overweight children have a number of factors that should be considered when they need to be sedated. Shorter necks, fatter cheeks, and limited mobility in the joints of the head and neck can complicate procedures.

· Higher body fat present in the neck which places pressure on the cricoid are of the neck making intubation more difficult and increases the likelihood of obstructive airway issues.

· Increased weight on the chest can cause require additional respiratory effort. Obese patients tolerate exercise poorly and can have large discrepancies in cardiac output and stroke volume. Being in a supine position can make these effects worse.

· Sleep apnea can be common in overweight patients and can be desensitize the receptors to higher levels of carbon dioxide.

· Fat soluble drugs (propofol) have initially the same effect as their weight dependant dosing but since there are larger fat stores the half life will be longer. This can make dosing of additional sedatives tricky.

· Nitrous is a good option for sedation because of its many benefits however, small amounts can accumulate in fat stores

Assessment of Article: Very nice review of complications that can arise from overweight patients. From my anesthesia experience I can see how sedating overweight patients does require extra care. Also, it is real hard to start an IV on overweight kids.

Monday, February 27, 2012

A Comparison of Two Meperdine/Hydroxyzine Sedation Regiments for the Uncooperative Pediatric Dental Patient

A Comparison of Two Meperidine/Hydroxyzine Sedation Regimens for the Uncooperative Pediatric Dental Patient

Justin W. Cathers, DDS, MS, Carolyn F.G. Wilson, DDS, MSD, Michael Webb, DDS, Marta E.D. Alvarez, BDS, Teresa Schiffman, PhD, Samuel Taylor, PhD

Pediatric Dentistry 27:5, 2005

Resident Meg

Purpose: To study the efficacy and safety of two methods of meperidine (oral and submucosal).

Method: Twenty children ages 30-66 months with documented negative behavior were randomly assigned to one of two groups.
One group was given Submucosal-administered Meperidine (SM) of 0.5 mg/lb along with 0.5mg Hydroxyzine first and the second visit OM Meperidine(Values below)
Second group was given oral administered Meperidine (OM) (1mg/lb) along with 0.5 mg Hydroxyzine followed up with a second visit of SM Meperdine (same values as above).
The patients were measured with Frankl and Houpt scores, differences in vital signs, side effects were noted, cooperation of the patient, effects of the drug and 'success.'

Results
*Success rate for SM was 63%
*Success rate for OM was 80%
*No difference in vital signs between the two groups
*The SM patients did experience pain and or burning at the injection site 11/20 patients total.
*Minor edema in the SM patients were seen in 3 children at the same visit and 2 more reported edema at the follow-up phone call.
*SM success rate was related to the patients ability to cooperate for radiographs during the first visit prior to sedation
*Of the children who received SM first 38% had successful sedation while 82% of those who received OM first had successful SM sedation at the second appointment.
*11 Children were successful with both treatments, 2 unsuccessful with either, 5 successful with OM only and one successful with SM only.

Discussion:

It's easy to see how the children's behavior would be worse after first receiving an OM injection. I would love to see a provider give this to a fearful patient as I've heard it can be very successful. Just with my little experience with oral sedation I realized that if the patient has a hard time cooperating with drinking a small amount of liquid the chances this this patient is going to cooperate for treatment is fairly slim.

Sunday, February 26, 2012

A Comparison of two oral ketamine-diazepam regimens for the sedation of anxious pediatric dental patients

Resident: Cho
Date: 2/29/2012

Author(s): Sullivan et al.
Journal: Pediatric Dentistry 23:3, 2001

Type of Journal: Scientific Article

Purpose: Compare 2 oral ketamine-diazepam regimens (8mg/kg ketamine + 0.1mg/kg diazepam; 10mg/kg ketamine + 0.1mg/kg diazepam) in unco-operative preschool age children needing restorative work.

Methods: 32 children were enrolled in the study, aged 30-66 months with past history of negative behavior, minimum of two restorative appointments requiring local anesthesia, ASA I or II, and airway at least 50% clear. Fasting times included at least 6 hours for solid foods and 3 hours for clear liquids. Vital signs were monitored throughout appointment and amnesia and behavior were also assessed.

Amnesia was tested with a cotton ball with a particular aroma and the location of the prize box being presented to the child before the sedation. The patient was either given the 8mg/kg ketamine in combination with diazepam the first appointment and then the 10mg/kg ketamine with diazepam the second appointment or vice versa.

Key points in the article discussion:

Of the 29 sedations in group A (8mg/kg), only 7 were successful sedations. Of the 22 failed sedations, 12 resulted in treatment being aborted. Of the 28 sedations in group B (10mg/kg), only 12 were successful sedations. Of the 16 failed sedations, 11 resulted in treatment being aborted. A total of 5 patients experienced psychic phenomenon. 50% of the patients vomited – of those patients, half vomited at the clinic.

There was no statistically significant difference in success between 8mg/kg ketamine group vs. 10mg/kg ketamine group. Results of this study do not support the use of 8mg/kg or 10mg/kg oral ketamine for the sedation of uncooperative children. The ability of ketamine to produce amnesia was not proven in this study.

Assessment of the article: The study never specified how much time elapsed between the first and second appointments. The time between appointments could have contributed to patient behavior and amnesia at the appointments. I was surprised that half of the patients vomited during the appointment. Even though, nitrous oxide may have helped the success of the sedations, the vomiting portion would probably make me wary of using oral ketamine.

Wednesday, February 22, 2012

Children Sedated For Dental Care: A Pilot Study of the 24-hour

Resident Name: Matthew Freitas
Title: Children Sedated For Dental Care: A Pilot Study of the 24-hourPostsedation Period
Author: S. Wilson et al
Journal: Pediatr Dent 2006;28:260-264

Purpose:
-The purpose of this study was to investigate post oral sedation events during the first 24 hours after discharge from the treatment facility after dental treatment. They did a comparison between a triple combo vs madiazolam as oral sedatives.

Methods:
-30 healthy patients, ranging from 2 to 5 years of age, sedated for operative procedures in the dental clinic.
-Depending on the extent of dental need, child tempera-ment, and other preoperative assessment variables, the children received either a triple combination [14 patients] of chloral hydrate, meperidine, and hydroxyzine ranging in dose from 20 to 30 mg/kg, 1 to 2 mg/kg, 1 to 2 mg/kg, respectively, or midazolam alone [16 patients] (0.5-0.75 mg/kg).
-Parents were asked to fill out a questionnaire concerning events that may occur during the 24 hours after the sedation and were called 24 hours later regarding the events.

Results/Key Points:
-Those receiving the combination regimen were more likely to sleep on the way to and at home than those who received midazolam alone.
-No differences found between the combination vs midazolam alone for postoperative pain,vomiting, eating, evening sleep, and memory.

Conclusion:
-The triple combination was more likely than midazolam to result in sleep during transit from the office to home, and these children were apparently more difficult to awaken. The concern is that apotential airway blockage may occur in transit or shortly after arriving at home. The child may be unable to maintain an open airway without assistance.
-The author emphasizes: 1. a dentist needs to rigidly adhere to discharge criteria of sedation guidelines; and 2. the profession needs to reassess and develop more specific and measurable discharge criteria for children prior to discharge from the health care facility.

The Physiologic and Behavioral Effects of Oral and Intranasal Midazolam in Pediatric Dental Patients

Resident Name: Elliot Chiu

Article Info

Title: The Physiologic and Behavioral Effects of Oral and Intranasal Midazolam in Pediatric Dental Patients

Author: Erin Johnson, DDS, MS

Journal: Pediatric Dentistry 2010

Main Purpose

-To compare the safety and effectiveness of oral and intranasal midazolam.

Methods

-31 children (8 males, 23 females) aged 2.5-7 y/o were split into 2 groups and seen for 2 appts

-Regimen A:

----1st appt: ORAL midazolam, intranasal spray placebo

----2nd appt: INTRANASAL midazolam with oral placebo

-Regimen B received the exact opposite of Regimen A for the 2 appts

-Oral liquid given 20min before start of tx, intranasal spray 10min before

-Pt placed onto a papoose board at the start of treatment. Pt was wrapped only if behavior became disruptive

-Crying/movement/overall behavior was rated at the baseline, papoose, LA, RD, start of operative, every 5min afterwards

Key Points

-Both oral and intranasal midazolam have similar behavioral outcomes

-At t=5min, the oral group showed significantly lower crying scores

-At t=papoose and t=5, the oral group showed significant improved overall behavior

-Providers report oral sedations to be “effective” or “very effective” significantly more often than intranasal sedations

-Desaturations occurred in both oral and intranasal sedations

Assessment

Well designed study. Both routes of administration are shown to be effective, but it seems the oral groups showed better behavior, especially early in the appt. If I were a patient, I’d probably rather drink something willingly than get sprayed in the nose.

Oral Midazolam with and without meperidine for management of the difficult young pediatric dental patient: a retrospecitive study

Oral Midazolam with and without meperidine for management of the difficult young perdiatric dental patient: a retrospective study

John E. Nathan, DDS, MDS
Kaaren G. Vargas, DDS, PhD

Pediatric Dentistry 24:2, 2002


Abstract: To examine the effectiveness of different dosages of midazolam used with or without meperidine to manage the difficult pediatric dental patient.

Methods: 120 patient records with sedation logs were reviewed. The subjects were divided into six groups based on dosages of midazolam alone or in combination with meperidine. 'Quality' of sedation was assessed as well as length of sedation; or working time and recovery time.

Results:
Higher doses of midazolam alone can produce better results in the severely apprehensive patient.
Children below the age of reason may require deeper levels of consciousness to permit invasive procedures
The addition of meperidine (1.0 mg/kg) doubled efficacy with 80% visits showing adequate or better ratings. In addition it also doubled working time from 8 to 18 minutes.
Higher doses of meperidine (1.0 mg/kg) did not show better results and warranted safety concerns for patients who were over sedated.

Discussion:
The definition of success varies from practitioner as well as parent. This was clearly evident from my short stay working in Hawaii. However, I do believe oral sedation is a good tool and option to use for some patients who are apprehensive about treatment. It can be very successful when used for the appropriately selected patient.

Comparison of Chloral Hydrate, Meperidene, and Hydroxyzine to Midazolam Regimens for Oral Sedation of Pediatric Dental Patients

Resident’s Name: Jessica Wilson
Article title: Comparison of Chloral Hydrate, Meperidene, and Hydroxyzine to Midazolam Regimens for Oral Sedation of Pediatric Dental Patients
Author(s): Chowdhury & Vargas
Journal: Pediatric Dentistry
Year. Volume (number). Page #’s: 2005. 27:3. 191-197.

Purpose:
To compare the effects of oral administration of a combination of chloral hydrate (CH), hydroxizine (H) and meperidine (M) to midazolam using 50% nitrous oxide (N2O).

Methods:
Records of 116 sedation sessions of 66 healthy, uncooperative children between the ages of 24 and 60 months at the University of Iowa were reviewed. Patients received one of 2 regimens:
1. 25 mg/kg CH, + 1 mg/kg of H + 1 mg/kg M + 50% N2O (45 min latent period).
2. 0.65 mg/kg midazolam + 50% N2O (25 min latent period).
Behavior, heart rate and oxygen levels were recorded at baseline and every 10 minutes intra-operatively and the sedation was assessed as excellent, adequate or inadequate.

Results:
Overall, 81% of sessions were rated as successful (34% excellent and 47% adequate). 89% of CH + H + M sedations were effective while only 70% of midazolam sessions were effective.
Sessions using CH + H + M had a significantly higher success rate when compared to those using midazolam.
Sedation success was not associated with age, behavior or type of dental procedure performed. Treatment need was the only statistically significant predictor in selecting 1 regimen over the other. Patients requiring 5-8 teeth were more than twice as likely to receive CH + H + M as patients requiring 3-4 teeth.

Conclusions:
CH + H + M lasted longer (40-49 min) vs. midazolam (15- 39 min).
CH + H + M was more likely to have a successful outcome than midazolam at the dosages described above.
Although with midazolam, heart rates increased when compared to CH + H + M, all vitals were WNL and appear to be safe.

Assessment of Article:
Great results and key information for those of us less experienced in oral sedation.

In case you didn't know... I'm getting married!!

Tuesday, February 21, 2012

The effect of midazolam premedication on discharge time in pediatric patients undergoing general anesthesia for dental restorations

Resident Name: Sadler
Article Info: The effect of midazolam premedication on discharge time in pediatric patients undergoing general anesthesia for dental restorations

Jason J. Horgesheimer DD

Pediatric Dentistry 23:6, 2001

Main Purpose: Determine is patients given midazolam before induction for treatment under GA influences recovery time.


Methods: 106 charts were chosen at random reviewed of children undergoing GA. 50 of the subjects got .5 mg/kg oral midazolam 30 minutes before induction 56 did not to serve as control. Demographic information and various in/out times were analyzed.

Key Points:

· Average age of patients treated was 3.8 years. Average OR time was 94.7 minutes with 34.9 minutes spent in the PACU. Total time from admission to discharge was 144.2 minutes.

· No statistical difference between the groups in age, weight or sex.

· No statistically significant result could be observed in discharge time between the group receiving the meds and the ones who didn’t (148.2 vs. 141.1).

· Conflicting studies have been published about the efficacy of premedication and this study supports the finding that there is no difference in recovery time.

· These findings are not to say that premedication is not useful. It can help relieve anxiety, ease induction, and aid in quality sleep after the procedure.

Assessment of Article: Very simple and easy to understand study. I think it would be better if there was consistency in the anesthesia protocols and agents as well as the nurses who discharged the patients. The article mentions other studies that have contradicting findings and it seems that the protocol seems to be whatever the anesthesia team feels is best.

Effect of submucosal midazolam on behavior and physiologic response When combined with Chloral hydrate and N2O

Resident: Swan
Article Title: Effect of Submocosal Midazolam on Behavior and Physiologic Response When Combined with Oral Chloral hydrate and nitrous oxide sedation
Authors: Myers GR, et al.
Journal: Pediatric Dentistry; 26:1, 2004

Purpose: examine the safety of the above mentioned OCS technique.

Methods:  20 kids ages 32 to 63 months included.  Selection criteria: ASA I, 2 to 5 years of age, uncooperative behavior, multiple restorative visits needed. Double blind crossover design; pts randomly assigned to receive either oral CH (50 mg/kg) and SM midazolam (.2 mg/kg) or oral CH (50 mg/kg) and SM saline placebo on first visit. On second visit pt received opposite regimen. 2nd visit scheduled within 4 weeks of first.  Single operator for all procedures.  50% N2O used during each visit. Behavior response rated as quiet, crying, movement, or struggling every 2 1/2 minutes for 40 minutes. Monitoring included capnograph, pulse oximeter, BP cuff, and precordial stethoscope. Vitals monitored.

Results: No serious adverse reactions with either drug regimen. 2 desaturation incidents (85 and 88%) that were quickly resolved with head repositioning and mouth suctioning. Both occurred during sedations with CH alone. No prolonged pain at SM injection site for any of the patients according to post operative evaluations. 

-the addition of SM midazolam (.2 mg/kg) to 50 mg/kg CH resulted in signicantly increased quiet behavior and decreased struggling behavior for an overall better quality of sedation compared to CH alone.
-Mean HR, RR, BP remained within normal range for these patients.

Discussion:  This was a nicely put together study that describes a technique that can be used as an option for sedation when pure CH sedation seems to not be enough.  It can be used as needed to augment the sedation without adding dangerously to total amount of CH.  With Midazolam use, need to be aware of possible paradoxical, "Exorcist"-like reactions. (2-10% of patients.)

Comparison of Oral Midazolam With and Without Hydroxyzine in the Sedation of Pediatric Dental Patients

Kyung-Hong Cal Kim

Comparison of Oral Midazolam With and Without Hydroxyzine in the Sedation of Pediatric Dental Patients

Author: Shapira J, Kupietzky A, Kadari A, Fuks AB, Holan G

Pediatric Dentistry 26:6, 2004

Purpose:
To compare the effectiveness of midazolam (MDZ) alone to a combination of MDZ and hydroxyzine (MDZH) when sedating young children for dental treatment.

Background information:
-Ideal premedication for sedation will provide safety, minimum respiratory depression, adequate sedation, minimal patient movement, early onset of drug action, and adequate working time
MDZ
-Potent bezodiazepine sedative hypnotic w/ anticonvulsant, muscle-relaxant, and amnesic effects
-Rapid onset
-Short-acting when used alone (not indicated for procedures > 20 minutes)
Hydroxyzine
-Antihistamine w/ a sedative and antiemetic properties
-Slower onset of action
-Longer duration of action

Methods:
-28 subjects b/w 21 and 56 months, w/ a mean age of 36.6 months
-Weight b/w 10 and 18 kg, w/ a mean weight of 13.8kg
-ASA I
-Required at least 2 restorative appts
-”Definitely negative” Frankl rating scale
-Each child randomly assigned to receive either 05.mg/kg or oral MDZ 20 minutes prior or 0.3mg/kg oral MDZ + 3.7mg/kg of hydroxyzine 30 minutes prior to dental tx. Pt to receive the alternative regimen at the second appt
-Placed in a papoose board w/ a pulse oximeter on a great toe
-50/50 N2O/O2 used as adjunct during each appt

Results:
Crying/quiet/sleep
-MDZ showed more children crying while MDZH presented more children asleep or quiet

Movement
-Presence of movement patter was similar in both MDZ and MDZH, with the incidences of movement increasing w/ tx time

General behavior rating
-No significant differences between the 2 regimens regarding overall behavior and success

Vital signs and adverse reactions
-Stable throughout tx procedures, no adverse reaction observed for both MDZ and MDZH

-Based on the results, study recommends using MDZ alone (given 20 minutes prior) for short dental procedures (extraction, PRR), and MDZH (given 30 minutes prior) for longer procedures.

Assessment of the article:
I believe it was a nicely designed study that allows comparison of effectiveness of both regimens on each child while being able to collect data for the two general groups based on the type of regimen used. As authors pointed out, this study was limited by its small sample size and the use of papoose boards for ALL patients that may have skewed the numbers for successful appts. It was still an interesting article that once again made me jealous that Jessi gets to try this (CS) out in Hawaii starting this week!

Comparison of Drops Versus Spray Adminsitration of Intranasal Midazolam in Two- and Three-year-old Children for Dental Sedation

Authors: Primosch, Robert E., MD, MEd, Gulemann, Marcio, DDS
Journal: Pediatric Dentistry, 27:5, 2005 401-408
Submitted by: Fotini Dionisopoulos

Purpose: This was a retrospective study of conscious sedation records of 2- and 3-year-olds receiving Intranasal Midazolam. Drops versus Spray administration was compared. Behavioral outcomes were observed for agent acceptance during administration and for agent efficacy during parental separation, local anesthesia injection and restorative treatment.

Methods:


  • Patient charts from the Pediatric Clinic at the Univ. Florida Dental School in Gainsville were randomly chosen (64 were accepted out of 72 chosen)


  • The behavior of the two groups (drops vs. spray) were compared


  • Temperament and attachment scores based on adaptability and approachability determinants judged by the parent and interactive and Frankl behavior rating scores determined by the operator were used to compare preoperative behavioral characteristics between the 2 groups


  • The Ohio State Behavioral Rating Scale (OSBRS) and the Frankl behavior rating scale were used to determine intraoperative behavioral outcomes for agent acceptance and efficacy.


Results:



  • An analysis of the behavioral characteristics of the subjects, as determined by the temperament (T), attachment (A), and interactive (I) scores, were not statistically different between the drops and spray administration groups. Therefore, both groups did not have remarkably different characteristics in temperament, attachement and interactive behavior.


  • Frankl behavior rating scores and the OSBRS had no significant differences between drops and spray. These groups also seemed to be similar in their behavior characteristics.


  • There was also no statistically significant difference for behavior during parental separation, local anesthesia administration and placement of dental restorations with drops vs. spray


  • During drug administration, the spray group had a statistically significant reduction in aversive behaviors compared to drops when measured by OSBRS.


  • It is recommended that more research is needed to determine the predictive value of various parameters affecting pediatric sedation behavior during treatment.
Conclusion: The administration of liquid midazolam can often be a challenge for the practitioner/parent/and patient. It is probably much more feasible to know that the nasal and drop routes have the same effect on cooperation-- it is certainly a more pleasure way to administer the midazolam, although I would assume the drops would be a little more cumbersome.