Effect of continuous versus interrupted administration of nitrous oxide-oxygen inhalation on behavior of anxious pediatric dental patients: a pilot study.

OBJECTIVE: The purpose of this study was to determine the effect of interrupted administration of nitrous oxide (N2O) inhalation, after obtaining profound local anesthesia, on the behavior of mild to moderately anxious pediatric patients during routine restorative dentistry. STUDY DESIGN: Healthy children, 5 to 8 years old, requiring nitrous oxide/oxygen inhalation sedation and bilateral mandibular restorative treatment performed in two sequential appointments under local anesthesia were recruited for this study. After profoundness of the local anesthesia was confirmed, the subject was randomly assigned to either Protocol A (50% N2O/50% O2) or Protocol B (100% O2) and restorative dental care was completed. On the second appointment, the subject was assigned to the alternate protocol. RESULTS: Hemoglobin oxygen saturation remained constant with no episodes of oxygen desaturation recorded. There were no statistically significant differences (P > .05) in pulse rate or behavior change noted between the two protocols. CONCLUSION: The implication of this pilot study was significant in consideration of the desire to minimize chronic exposure to ambient nitrous oxide and its potential health hazards to the dental team. These findings challenge the traditional practice of N2O maintenance throughout the dental appointment.

Influence of operatory size and nitrous oxide concentration upon scavenger effectiveness.

Concern regarding environmental health hazards for dental personnel chronically exposed to waste nitrous oxide (N2O) prompted this investigation. The influence on ambient N2O levels of scavenging, operatory size, and N2O concentration delivered to the patient was evaluated during treatment of 36 pediatric dental patients. The results showed that scavenging significantly reduced ambient N2O levels measured at 50-56 cm from the patient's nose. Scavenged ambient N2O levels were also observed to decrease when N2O concentrations administered to the patient were reduced from 50 to 30%. This concentration effect was not observed in the non-scavenged groups. ANOVA showed that operatory size exerted a non-significant influence on ambient N2O. The data collected during routine treatment of pediatric dental patients demonstrated that the scavenging system tested significantly reduced waste N2O in the operator's breathing zone, nearly approximating the 25-ppm recommendation established by the National Institute for Occupational Safety and Health (NIOSH).

Distribution and retention of salivary fluoride from a sodium fluoride tablet following various intra-oral dissolution methods.

The distribution and retention of salivary fluoride were investigated according to the following intra-oral dissolution methods of a sodium fluoride tablet: active chewing/swishing, active sucking/swishing, and passive dissolution in the maxillary and mandibular labial vestibule. The results suggested that the oral cavity was somewhat compartmentalized, in that homogeneous distribution of a dissolved fluoride tablet did not occur throughout the mouth, but rather each site sampled was influenced by various rates of clearance and retention. Tablet chewing may have an advantage over tablet sucking in terms of salivary fluoride retention, and there was a tendency for fluoride to be preferentially retained in the maxillary labial vestibule following swishing. The passive tablet dissolution methods resulted in a less homogeneous distribution of fluoride. Although the fluoride retention values for passive dissolution were impressively superior to either active dissolution method, the alarmingly high salivary fluoride concentrations (4000 ppm F) recorded at the passive dissolution sites should discourage its use until the potential cytotoxicity of this approach is thoroughly investigated.

Operatory ventilation and scavenger evacuation rate influence on ambient nitrous oxide levels.

Investigations have shown that greater than Federally-recommended levels of ambient nitrous oxide often exist in the dental workplace. The purposes of this investigation were to examine the influences of (1) operatory ventilation rate and (2) scavenger evacuation rate on ambient nitrous oxide concentrations within a closed dental operatory. This laboratory investigation utilized a scavenging nasal mask assembly (Porter/Brown) to deliver 40% nitrous oxide in oxygen, at a total flow rate of 5 L/min, to a mannequin positioned supinely in a dental chair. Eight experimental groups were assigned based on combinations of operatory air exchange rates (0, 5, 10, or 15 room air changes per hour) and scavenger evacuation rates (18.8 L/min and 21.4 L/min). Ambient nitrous oxide levels were monitored at four locations (0, 15.3, 30.7, and 61.4 cm) from the nasal mask by means of an infrared spectrophotometer (Miran 1B). The operatory air exchange rate was measured with a flow hood (Short Ridge) and manipulated to one of the desired ventilation rates. Time-weighted average (TWA) concentrations of ambient nitrous oxide (ppm) were continuously recorded at 15-second intervals with a microprocessor (DL332F Datalogger) connected directly to a microcomputer. The results demonstrated that significantly reduced (p < 0.05) ambient nitrous oxide levels were achieved with increasing room air exchange rates and the high scavenger evacuation rate. It was concluded that operatory ventilation and scavenger evacuation rates were significant control measures available for reduction of ambient nitrous oxide to Federally recommended levels.

Effect of family structure on the dental caries experience of children.

It was the purpose of this study to investigate several variables in family structure which might influence the caries experience in 3-12-year-old children for Central Oklahoma. These variables, which included parental age at marriage and at birth of the child for both mother and father, birth rank, family size, and age span differences between the siblings, were investigated in an attempt to identify those children at greatest risk to dental caries formation. It was suggested that differences in the caries experience for children from various family structures might be the result of the families' socioeconomic status and its influence upon the child's dietary habits. Because dental caries is a multifactorial disease complex governed by so many factors, single correlations between variables in family structure and a child's caries prevalence are not necessarily sufficient by themselves to form a basis for selection of high risk children. It should not be overlooked that subtle differences in family structure, however, may have significant consequences for a particular individual.

Sealant use and placement techniques among pediatric dentists.

BACKGROUND: Pit and fissure sealant use varies widely among dentists. The authors conducted a survey to determine the current variations and patterns of sealant placement among pediatric dentists. METHODS: The authors mailed a 20-question survey to American Academy of Pediatric Dentistry members from six states, who represented one-third (1,210) of the membership, as well as to all 52 pediatric dentistry departments in U.S. dental schools. The authors examined selection criteria, placement techniques, evaluation methodologies, and the one- and three-year estimated success and reapplication rates of sealant placement. RESULTS: The response rates were 70 percent for practitioners and 90 percent for dental schools. Approximately 80 percent of respondents said they sealed caries-free and questionable carious surfaces. Only 20 percent of the respondents said they sealed incipient carious surfaces; none said they would seal overt caries. Surface preparation was used always or sometimes by 87 percent of the respondents. The estimated one- and three-year sealant retention rates were 89 percent and 78 percent, respectively, for practitioners and 83 percent and 71 percent, respectively, for dental schools. CONCLUSIONS: The survey demonstrated wide variations in selection criteria, placement techniques and evaluation methodologies, yet showed remarkable similarities between practitioners and dental schools. The reported retention rates were consistent with those reported in the literature. PRACTICE IMPLICATIONS: The survey results suggested that pediatric dentists were searching for evidence-based selection criteria and a technique protocol for sealant placement that improved clinical success. The wide technique variations reported were likely a result of training diversity, diagnostic uncertainty, technique and material sensitivity, and an attempt to improve the success rate.

Pseudobattering of Vietnamese children (cao gio).

The case of a Vietnamese child who was subjected to the folk medicine practice of cao gio by his father after a routine dental extraction is described. The practice and the clinical appearance are discussed to distinguish it from child abuse.

Pain elicited during intraoral infiltration with buffered lidocaine.

PURPOSE: To evaluate the effect of buffered lidocaine with self reporting of pain elicited during maxillary labial and palatal infiltrations of permanent canines. MATERIALS AND METHODS: A standardized, prospective clinical trial of adult volunteers using a cross-over design of 20 paired injections using conventional 2% lidocaine with 1:100,000 epinephrine as the control. RESULTS: Failed to establish a significant reduction in pain scores for either injection site when buffered lidocaine was injected intraorally.

Comparison of topical EMLA 5% oral adhesive to benzocaine 20% on the pain experienced during palatal anesthetic infiltration in children.

PURPOSE: The purpose of this investigation was to compare the pain responses of children during local anesthetic infiltration at bilateral palatal sites prepared with the topical application of benzocaine 20% oral adhesive (Orabase-B) versus benzocaine 20% gel (Hurricaine) or EMLA 5% oral adhesive (EMLA 5% cream in Orabase Plain). METHODS: Forty subjects, aged 7-15 years old, received bilateral palatal injections following topical application of anesthetic agents applied in a randomized, crossover design. Pain responses were compared based upon subject self-report using a visual analogue scale (VAS), changes in the subject's heart rate, and operator assessment using a modified Children's Hospital of Eastern Ontario Pain Scale (CPS) that rated behavioral changes in children. Following the injections, the subjects were asked to choose which agent was preferred based on comfort and taste acceptance. RESULTS: All the agents tested were equivalent in injection pain response comparisons, but Hurricaine had a slight advantage in expressed subject preference and taste acceptance over the other topical anesthetic agents tested. CONCLUSIONS: The selection of EMLA 5% oral adhesive over other commercially available products containing benzocaine 20% is not recommended for palatal site preparation in children. The lack of demonstrated superiority in efficacy and subject preference, the necessity to custom mix the cream into an oral adhesive paste, the extended duration of time required for onset of action, the greater potential for complications associated with systemic absorption, and product cost preclude the use of EMLA 5% oral adhesive as an intraoral topical anesthetic agent.

Monitoring pediatric dental patients with nasal mask capnography.

PURPOSE: The purpose of this study was to evaluate the potential of using capnography to analyze respiratory samples taken from a scavenging nitrous oxide nasal hood during routine pediatric dental procedures. METHODS: Twenty-two subjects, aged 60-116 months, were administered alternately either 40% nitrous oxide/60% oxygen or 100% oxygen during two sequential restorative appointments. All subjects were monitored continuously for end-tidal carbon dioxide and respiratory rate using a capnograph whose sampling line was attached directly to the nitrous oxide nasal hood. The subject's breath sound, displayed behavior, type of dental procedure being performed, and presence of rubber dam isolation were recorded every minute throughout the two appointments. RESULTS: Values for end-tidal carbon dioxide and respiratory rate were displayed on the capnograph when administering either oxygen or a combination of nitrous oxide/oxygen inhalation through the nasal hood. These respiratory values were lowered significantly when comparing 40% nitrous oxygen-60% oxygen to 100% oxygen inhalation. They were not significantly altered by the type of breath sound, patient behavior, dental procedure, or presence of rubber dam isolation, with the exception of some dental procedures which significantly lowered end-tidal carbon dioxide. The apnea alarm on the capnograph occurred during 5% of the total treatment time, but its occurrence represented a 97% false positive rate. The occurrence of the apnea alarm was significantly associated with the type for breath sound, patient behavior, and dental procedure. When used in this manner, the capnograph was effective in alerting the practitioner to potential apneic events, but likely has limited value in monitoring valid end-tidal carbon dioxide levels due to limitations in the sampling technique. CONCLUSIONS: This study demonstrated the potential of the capnograph as a respiratory monitor for pediatric dental patients when the sampling line was attached to a scavenging nitrous oxide nasal hood.

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.

Primary tooth pulp therapy as taught in predoctoral pediatric dental programs in the United States.

A survey of all predoctoral pediatric dental programs in the United States was conducted to ascertain the contemporary teaching philosophies and techniques for pulp therapy in primary teeth. All 53 predoctoral programs responded to a two-part survey consisting of multiple choice questions regarding which pulp therapies and specific techniques were taught and which pulp therapies would be employed under certain hypothetical clinical scenarios. The results of the survey confirmed some lack of consensus on the selection and application of certain treatment modalities and techniques taught for primary tooth pulp therapy in predoctoral dental programs in the United States.

The effects of various dental procedures and patient behaviors upon nitrous oxide scavenger effectiveness.

This prospective study of 36 children, ages 44-93 months, receiving nitrous oxide-oxygen under standardized conditions during routine dental procedures was conducted to determine what influence eight selected dental procedures and three patient behaviors had on ambient nitrous oxide (N2O) levels in the dentist's breathing zone. Half the children received nitrous oxide-oxygen via a scavenging nasal mask. An infrared spectrophotometer analyzed the ambient N2O level continuously throughout the procedure and the time-weighted average (TWA) for consecutive 15-sec intervals was recorded by a microprocessor. A video camera was used to synchronize the coded dental procedures and patient behaviors to the TWA ambient N2O levels recorded. The results demonstrated that scavenging significantly reduced the dentist's exposure to ambient N2O (P less than 0.05, nonscavenged mean = 284.7 ppm; scavenged mean = 36.6 ppm), but the mean TWA N2O concentration remained significantly higher, P less than 0.05, than the 25-ppm level recommended by the National Institute for Occupational Safety and Health (NIOSH). Supplemental oral evacuation was the only dental procedure capable of reducing ambient N2O to below NIOSH's recommendation when scavenging was employed. The administration of local anesthesia consistently created a significant increase in ambient N2O levels. Patient behaviors of talking, crying, and movement also resulted in significant increases from baseline ambient N2O levels.

Clinical effectiveness of 1 and 2% lidocaine in young pediatric dental patients.

Clinical effectiveness of the double-blind administration of 1 and 2% lidocaine solutions was evaluated for restorative and surgical procedures on primary molars of children 4.5 to 10.5 years old. This effectiveness was measured by changes in the child's heart rate, the child's self report of pain, and the operator's assessment of the anesthesia's effectiveness. Although the incidence of anesthetic failure was higher for the 1% solution (31.3%) than for the 2% solution (11.1%), no statistically significant difference between the solutions was found. During the performance of pulpotomies and extractions, a higher failure rate was recorded for the 1% solution (62.5%) than for the 2% solution (28.6%), but these differences were not statistically significant. For minor restorative procedures, the 1% solution was equally successful in achieving anesthesia. The results suggested that 1% lidocaine should be used when multiple minor procedures are performed and potential toxicity in the young dental patient is a concern.

Comparison of preoperative ibuprofen, acetaminophen, and placebo administration on the parental report of postextraction pain in children.

Previous investigations demonstrated that administering a preoperative analgesic can reduce postextraction pain in adults. Studies also have shown that ibuprofen was superior in alleviating postextraction pain when compared with acetaminophen. The purpose of this study was to compare the efficacy of the preoperative administration of ibuprofen, acetaminophen, and placebo in reducing postextraction pain in children. Sixty children, aged 2-10 years, requiring primary teeth extractions, were selected to participate in the study. Patients were assigned in a blind, random fashion to one of the three pretreatment drug groups. Parental report of their child's pain and use of analgesics during the immediate 7-hr postoperative period was elicited by telephone the day after the extraction procedure. Thirty-five percent of the patients were reported by their parents to experience postextraction pain. Of those patients, 52% received postoperative analgesics for pain relief (18% of the total). Although there was a trend toward reduced postextraction pain reported by the parents, the preoperative administration of neither analgesic was found to be statistically superior by chi-square analysis to placebo administration.

Variables influencing hemoglobin oxygen desaturation in children during routine restorative dentistry.

Pulse oximetry to monitor oxygen saturation during pediatric dental sedations has revolutionized the early detection of hypoxemia. Previous sedation studies confirmed the occurrence of hemoglobin oxygen desaturation when sedative agents are administered in conjunction with nitrous oxide. The purpose of this study was to monitor the hemoglobin oxygen saturation levels of nonmedicated pediatric patients during routine restorative procedures to study the effect of nitrous oxide, chronologic age, tonsil size, and lidocaine dose. Two identical pulse oximeters and probes were attached to a patient's right and left feet to validate the occurrence of oxygen desaturations. The results revealed that 20.3% of the patients demonstrated at least one occurrence of oxygen desaturation during the routine dental procedure. Administration of nitrous oxide had no effect on the prevalence of oxygen desaturation. Although chronologic age, tonsil size, and lidocaine dose did not exert a statistically significant influence when analyzed independently, when combined they were related statistically (P < 0.0001) to the occurrence of oxygen desaturation as defined by the parameters of the study. These data suggest that some of the oxygen desaturations recorded during routine restorative appointments may result from probe error and a combination of patient-related variables.

Oral manifestations of Menkes' kinky hair syndrome.

Menkes' Kinky Hair Syndrome (MKHS) comprises an array of clinical manifestations including hair shaft abnormalities, epidermal hypopigmentation, and progressive cerebral degeneration that are transmitted as an X-linked recessive disorder affecting copper transport pathways in primarily young males. The oral manifestations of MKHS are scantly reported to include the presence of gingival enlargement and delayed eruption of primary teeth. The purpose of this report is to present a case of MKHS describing the intraoral clinical findings.

Oral arginine metabolism may decrease the risk for dental caries in children.

Arginine metabolism by oral bacteria via the arginine deiminase system (ADS) increases the local pH, which can neutralize the effects of acidification from sugar metabolism and reduce the cariogenicity of oral biofilms. To explore the relationship between oral arginine metabolism and dental caries experience in children, we measured ADS activity in oral samples from 100 children and correlated it with their caries status and type of dentition. Supragingival dental plaque was collected from tooth surfaces that were caries-lesion-free (PF) and from dentinal (PD) and enamel (PE) caries lesions. Regardless of children's caries status or type of dentition, PF (378.6) had significantly higher ADS activity compared with PD (208.4; p < .001) and PE (194.8; p = .005). There was no significant difference in the salivary arginolytic activity among children with different caries status. Mixed-model analysis showed that plaque caries status is significantly associated with ADS activity despite children's age, caries status, and dentition (p < .001), with healthy plaque predicting higher ADS activity compared with diseased plaque. Plaque arginine metabolism varies greatly among children and tooth sites, which may affect their susceptibility to caries.