The Influence of Side Effect Information Framing on Nocebo Effects.

BACKGROUND: One contributing factor to the development of nocebo effects is information provided about possible side effects. However, nondisclosure of information can be problematic. PURPOSE: We assessed whether positively framed side effect information (highlighting likelihood of not experiencing side effects) can reduce nocebo effects compared to negatively framed information (highlighting likelihood of experiencing side effects). METHODS: One hundred twelve participants took part in research ostensibly assessing the influence of benzodiazepines (actually sham capsules) on anxiety. Participants were randomized to receive a sham capsule with positively or negatively framed information about four side effects, or a no-treatment control condition. Side effect expectations were assessed after information provision. Framed side effects and other unmentioned symptoms were assessed during the session and 24-hr follow-up. RESULTS: Nocebo effects occurred in symptoms presented as side effects (regardless of framing) during the study session and follow-up (ps < .003). At follow-up, there was also a nocebo effect in other unmentioned symptoms (p = .018). Positive framing reduced side effect symptoms compared with negative framing during the study session (p = .037), but this effect was no longer present at follow-up (p = .53). Side effect expectations did not differ between the framing conditions (p = .14). CONCLUSIONS: Positive framing reduced side effects short-term, but not at follow-up. Expectations did not differ between negative and positive framing. Nocebo effects appeared to generalize to other unmentioned symptoms over a 24-hr period. Further research is needed to determine whether the initial impact of positive framing can be maintained over time.

Comparison of Three Anxiety Management Protocols for Extraction of Third Molars With the Use of Midazolam, Diazepam, and Nitrous Oxide: A Randomized Clinical Trial.

PURPOSE: The objective of the present study was to compare 3 sedation protocols using diazepam, midazolam, and nitrous oxide. PATIENTS AND METHODS: A total of 120 patients with an indication for extraction of third molars were selected. All 120 patients had had moderate to severe levels of anxiety according to the Corah Dental Anxiety Scale. The patients were randomly divided into 3 groups. The patients' vital signs were measured, and the results analyzed by descriptive statistical analysis and statistical tests of comparison. RESULTS: No statistically significant differences were found in the patients' heart rate. However, the differences in the systolic and diastolic blood pressure were statistically significant after 15 minutes of nitrous oxide sedation. The oximetry data showed no differences among the 3 sedation protocols. We also found no statistically significant differences in the retrograde amnesia test. The differences in anxiety from preoperatively to postoperatively were statistically significant for all techniques, demonstrating their effectiveness in anxiety control. CONCLUSIONS: All 3 preoperative sedation techniques for anxious patients undergoing extraction of third molars used in the present study were effective in controlling the anxiety, with little effect on the patients' vital signs and retrograde amnesia.

Conscious Sedation in Dentistry.

Invasive dental procedures can be performed only with local anesthesia; in some cases, it may be useful to combine the administration of drugs to obtain anxiolysis with local anesthesia. Sedation required level should be individually adjusted to achieve a proper balance between the needs of the patient, the operator, and the safety of the procedure. Surgical time is an important factor for post-operative phases, and this could be greatly increased by whether the patient interrupts the surgeon or if it is not collaborative. In this manuscript some dentistry-used methods to practice conscious sedation have been evaluated. This manuscript could be a useful reading on the current state of conscious sedation in dentistry and an important starting point for future perspectives. Surely the search for safer drugs for our patients could have beneficial effects for them and for the clinicians.

Sedation of children undergoing dental treatment.

BACKGROUND: Children's fear about dental treatment may lead to behaviour management problems for the dentist, which can be a barrier to the successful dental treatment of children. Sedation can be used to relieve anxiety and manage behaviour in children undergoing dental treatment. There is a need to determine from published research which agents, dosages and regimens are effective. This is the second update of the Cochrane Review first published in 2005 and previously updated in 2012. OBJECTIVES: To evaluate the efficacy and relative efficacy of conscious sedation agents and dosages for behaviour management in paediatric dentistry. SEARCH METHODS: Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 22 February 2018); the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 1) in the Cochrane Library (searched 22 February 2018); MEDLINE Ovid (1946 to 22 February 2018); and Embase Ovid (1980 to 22 February 2018). The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. SELECTION CRITERIA: Studies were selected if they met the following criteria: randomised controlled trials of conscious sedation comparing two or more drugs/techniques/placebo undertaken by the dentist or one of the dental team in children up to 16 years of age. We excluded cross-over trials. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted, in duplicate, information regarding methods, participants, interventions, outcome measures and results. Where information in trial reports was unclear or incomplete authors of trials were contacted. Trials were assessed for risk of bias. Cochrane statistical guidelines were followed. MAIN RESULTS: We included 50 studies with a total of 3704 participants. Forty studies (81%) were at high risk of bias, nine (18%) were at unclear risk of bias, with just one assessed as at low risk of bias. There were 34 different sedatives used with or without inhalational nitrous oxide. Dosages, mode of administration and time of administration varied widely. Studies were grouped into placebo-controlled, dosage and head-to-head comparisons. Meta-analysis of the available data for the primary outcome (behaviour) was possible for studies investigating oral midazolam versus placebo only. There is moderate-certainty evidence from six small clinically heterogeneous studies at high or unclear risk of bias, that the use of oral midazolam in doses between 0.25 mg/kg to 1 mg/kg is associated with more co-operative behaviour compared to placebo; standardized mean difference (SMD) favoured midazolam (SMD 1.96, 95% confidence interval (CI) 1.59 to 2.33, P < 0.0001, I2 = 90%; 6 studies; 202 participants). It was not possible to draw conclusions regarding the secondary outcomes due to inconsistent or inadequate reporting or both. AUTHORS' CONCLUSIONS: There is some moderate-certainty evidence that oral midazolam is an effective sedative agent for children undergoing dental treatment. There is a need for further well-designed and well-reported clinical trials to evaluate other potential sedation agents. Further recommendations for future research are described and it is suggested that future trials evaluate experimental regimens in comparison with oral midazolam or inhaled nitrous oxide.

[Local anesthesia selection algorithm in patients with concomitant disease. Part 2.] / Algoritm okazaniya stomatologicheskoi pomoshchi patsientam s soputstvuyushchei patologiei. Chast' 2.

A group of authors presents the rationale for local anesthesia selection in patients with concomitant disease based on case history; interaction analysis of drugs with local anesthetic and sedation agents; estimation of patient functional status; patient anxiety correction; dental care with hemodynamics monitoring. It was found that adhering to this algorithm promotes the prevention of urgent conditions in outpatient settings.

[Administration of intravenous sedation with midazolam by dentists is unsafe]. / Toediening van intraveneuze sedatie met midazolam door tandarts is onveilig.

In the December issue of the Nederlands Tijdschrift voor Tandheelkunde (Dutch Journal of Dentistry) in 2014, an article was devoted to the use of light sedation with midazolam by dentists. A number of dentists who are active in the area of Special Dentistry (anxiety management, care of the disabled) and a anesthesiologist offer a response to the article and argue that the administration of intravenous sedation with midazolam by dentists is unsafe.

[Safety of intravenous sedation with midazolam for dental treatment]. / Veiligheid van sedatie met midazolam voor tandheelkundige behandelingen.

In the December 2014 issue of the Nederlands Tijdschrift voor Tandheelkunde, T.H. van den Berg and B. Preckel published an article entitled 'Mild intravenous sedation with midazolam by dentists'. Broers et al responded to this article arguing that the administration of intravenous sedation with midazolam by dentists is unsafe for patients. In the current article the authors, Van den Berg and Preckel, address the points of criticism.

The application of drug behavior management methods in the treatment of dental fear and oral diseases in children: A review.

Oral behavior management methods include basic behavior management methods and drug behavior management methods. In many cases, dental treatment that cannot be done simply through basic behavior management is not possible. The uncooperative behavior of children with dental fear in oral treatment has increased the demand for medication based behavior management methods. Drug sedation can provide more effective analgesic and anti-anxiety effects, thereby helping to provide comfortable, efficient, and high-quality dental services. This article will review the drug sedation methods selected in clinical treatment of pediatric dental fear in recent years, as well as the safety and effectiveness of commonly used drugs, in order to provide guidance for dental professionals in clinical practice.

Dentists' skills with fearful patients: education and treatment.

The aims were to explore dentists' skills in dental fear, current strategies when treating fearful adult patients, and the possible need for additional education among dentists working in Sweden. A sample of 1,293 members of the Association of Public Health Dentists in Sweden were asked to respond to a Web survey concerning dental fear. The response rate was 69% (n = 889); 91% trained in Sweden and 9% trained in another country. The most frequently used pharmacological anxiety-reducing techniques were medication with a midazolame mixture (72%) and benzodiazepine tablets (77%), and the most commonly used psychological techniques were relaxation (68%), distraction (66%), and Tell-Show-Do (86%). A larger proportion of dentists trained in Sweden, compared with dentists who were trained in other countries, reported that they had received undergraduate training in dental fear. Dentists trained in Sweden more often reported competence in pharmacological and psychological anxiety-reducing techniques, compared with dentists who were trained in other countries. Higher levels of self-rated efficacy in treating fearful patients accompanied additional education in dental fear after graduation. In conclusion, Swedish dentists use a variety of techniques to meet the needs of fearful dental patients. Competence in anxiety-reducing techniques is associated with self-efficacy and the site of education.

The role of dental therapists in pharmacological and non-pharmacological treatment of anxious and phobic patients.

Dental Therapists are in a prime position to be involved with the management of anxious and phobic patients. They earn less than dentists and are therefore a more cost-effective way of providing specialised care for anxious patients. Dental Therapists can spend more time educating and acclimatising these patients, do most if not all of the patient's treatment, only referring back to the dentist for RCT, crown/bridgework/dentures and permanent extractions. Ultimately this means that the patient receives high quality continuity of care. Treating anxious and phobic patients is time-consuming but ultimately very rewarding. If handled correctly and sensitively the anxious and phobic patient will not always be anxious or phobic, in the same way that children won't always be children. Dental Therapists can now extend their duties to include Relative Analgesia. This should enhance their employability and role within the dental team especially in the management of anxious and phobic patients. Employing a therapist with a toolbox of techniques at their disposal can be seen as part of a long-term practice plan to ensure that anxious and phobic patients become rehabilitated, happy, compliant and loyal to the practice! In fact .... the sort of patients every dentist really wants to see.

A double blind randomized trial of ketofol versus propofol for endodontic treatment of anxious pediatric patients.

OBJECTIVE: To find out the safe and efficient sedative agent for primary molar pulpectomy in uncooperative pediatric patients. STUDY DESIGN: This double blind randomized trial enrolled 40 anxious and healthy 2-6 year olds. All subjects received IV propofol (1-1.5 mg/kg) or ketofol (1-1.5 mg/kg propofol with 0.25 mg/kg ketamine) as per group assignment after oral midazolam premedication (0.5 mg/kg). Sedation maintenance was done with propofol infusion at 25-75 microg/kg/min titrated to a predefined Worse level as per Houpt's sedation rating scale. Additional bolus/es was/were administered in the dosage similar to induction dose in case of inadequate sedation. Primary outcomes were intraoperative and postoperative adverse events. Secondary outcomes were vital signs, success of procedure, operator satisfaction, sedation quality, treatment time, recovery time and total propofol dose. RESULTS: Significantly greater incidence of respiratory depression was reported for ketofol group (11/20; 55%) when compared to propofol group (3/20; 15%) (p = 0.008). Desaturation was the most common adverse respiratory event with significantly greater incidence in ketofol group (9/20; 45%) when compared to propofol only group (3/20; 15%) (p = 0.033). No significant differences regarding secondary outcomes were reported in two groups. CONCLUSION: Both the regimen exhibited similar sedation profile while propofol alone emerged as a safer option.

Sedation of children undergoing dental treatment.

BACKGROUND: Children's fear about dental treatment may lead to behaviour management problems for the dentist, which can be a barrier to the successful dental treatment of children. Sedation can be used to relieve anxiety and manage behaviour in children undergoing dental treatment. There is a need to determine from published research which agents, dosages and regimens are effective. OBJECTIVES: To evaluate the efficacy and relative efficacy of conscious sedation agents and dosages for behaviour management in paediatric dentistry. SEARCH METHODS: Electronic searches of MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Dissertation Abstracts, SIGLE, the World Wide Web (Google) and the Community of Science Database were conducted for relevant trials and references up to 4th August 2011. Reference lists from relevant articles were scanned and the authors contacted to identify trials and obtain additional information. There were no language restrictions. Trials pre-1966 were not searched. SELECTION CRITERIA: Studies were selected if they met the following criteria: randomised controlled trials of conscious sedation comparing two or more drugs/techniques/placebo undertaken by the dentist or one of the dental team in children up to 16 years of age. Crossover trials were excluded. DATA COLLECTION AND ANALYSIS: Information regarding methods, participants, interventions, outcome measures and results were independently extracted, in duplicate, by two review authors. Where information in trial reports was unclear or incomplete authors of trials were contacted. Trials were assessed for risk of bias. The Cochrane Collaboration statistical guidelines were followed. MAIN RESULTS: Thirty-six studies were included with a total of 2810 participants. Thirty trials (83%) were at high risk of bias and six (17%) were at unclear risk of bias. There were 28 different sedatives used with or without inhalational nitrous oxide. Dosages, mode of administration and time of administration varied widely. Trials were grouped into placebo-controlled, dosage and head-to-head comparisons. Meta-analysis of the available data was possible for studies investigating oral midazolam vs placebo only. There is weak evidence from five small clinically heterogeneous trials at high risk of bias, that the use of oral midazolam in doses between 0.25 mg/kg to 0.75 mg/kg is associated with more co-operative behaviour compared to placebo; standardised mean difference (SMD) favoured midazolam (SMD 2.98, 95% confidence interval (CI) 1.58 to 4.37, P < 0.001, I² = 91%), which translates to an increase of approximately 1.8 points on the six-point Houpt behaviour scale. There is very weak evidence from two trials which could not be pooled that inhalational nitrous oxide is more effective than placebo. AUTHORS' CONCLUSIONS: There is some weak evidence that oral midazolam is an effective sedative agent for children undergoing dental treatment. There is very weak evidence that nitrous oxide inhalation may also be effective. There is a need for further well designed and well reported clinical trials to evaluate other potential sedation agents. Further recommendations for future research are described and it is suggested that future trials evaluate experimental regimens in comparison with oral midazolam or inhaled nitrous oxide.

Weak evidence that oral midazolam is an effective sedative agent for children undergoing dental treatment.

DATA SOURCES: Medline, Embase, Cochrane Central Register of Controlled Trials, Dissertation Abstracts, SIGLE, the WorldWideWeb (Google) and the Community of Science Database were searched for relevant trials and references. Reference lists from relevant articles were scanned and the authors contacted to identify trials and obtain additional information. There were no language restrictions. Trials pre-1966 were not searched. STUDY SELECTION: Studies were included if they were randomised controlled trials of conscious sedation comparing two or more drugs/techniques/placebo undertaken by the dentist or one of the dental team in children up to 16 years of age. DATA EXTRACTION AND SYNTHESIS: Reference lists from relevant articles were scanned and the authors contacted to identify trials and obtain additional information. There were no language restrictions. Trials pre-1966 were not searched. RESULTS: Thirty-six studies (2810 participants) were included. The majority of the trials (30) were of high risk of bias, the other six trials were at unclear risk of bias. Twenty-eight different sedatives were used with or without inhalational nitrous oxide, and the dosages, mode and timing of administration varied greatly. The trials were grouped into placebo-controlled, dosage and head-to-head comparisons. Meta-analysis was possible for studies investigating oral midazolam vs placebo only. There is weak evidence from five trials at high risk of bias, that the use of oral midazolam in doses between 0.25 mg/kg to 0.75 mg/kg is associated with more co-operative behaviour compared to placebo; standardised mean difference (SMD) favoured midazolam (SMD 2.98, 95% CI 1.58 to 4.37, P < 0.001, I² = 91%). There was also very weak evidence from two trials which could not be pooled that inhalational nitrous oxide is more effective than placebo. CONCLUSIONS: There is some weak evidence that oral midazolam is an effective sedative agent for children undergoing dental treatment. There is very weak evidence that nitrous oxide inhalation may also be effective. There is a need for further well designed and well reported clinical trials to evaluate other potential sedation agents. Further recommendations for future research are described and it is suggested that future trials evaluate experimental regimens in comparison with oral midazolam or inhaled nitrous oxide.

Intravenous sedation management for an outpatient with dental phobia and vasovagal reflex following an atrioventricular junctional rhythm: A case report.

Perioperative arrhythmias may be induced by an imbalance between sympathetic and parasympathetic activities owing to excessive mental and physical stress. To date, no studies have been conducted on intravenous sedation (IVS) during dental procedures in a serious dental anxiety patient with atrioventricular junctional rhythm (AVJR). We describe herein the management of IVS in an outpatient with dental phobia who experienced the AVJR followed by vasovagal reflex (VVR) during dental care. A 26-year-old woman with serious dental anxiety was scheduled for dental extraction under intravenous conscious sedation. A II-lead electrocardiogram revealed AVJR following sinus rhythm. Immediately afterwards, she experienced VVR with dimmed vision, cold sweat, hypotension, and bradycardia. She was made to relax in the supine position, which restored hemodynamics to normal, and sinus rhythm followed. She was optimally sedated with midazolam 4 mg and uneventfully treated under a preparation of intravenous atropine, and hemodynamic and respiratory statuses were closely monitored to ensure spontaneous breathing without any signs of AVJR or cardiorespiratory disorders. Finally, flumazenil 0.5 mg was administered, and she recovered without re-sedation or prolonged sedation. The autonomic nervous system and endocrine system are closely related in order to control the stress responses. The present case suggests that an electrocardiographic change such as AVJR is induced by an imbalance of autonomic activity owing to excessive psychosomatic stress and is considered as a possible prodromal sign of VVR as the dental procedures are likely to be stressful for some patients.

Treatment planning for the pediatric patient.

Treatment planning for pediatric dental patients is a multifactorial, complex process that requires careful consideration of three distinct areas: the patient's caries risk status, the available treatment options and the child's behavior. Components of a caries risk assessment include: a review of the child's medical and dental history in combination with the findings of the clinical and radiographic examination. All decisions regarding appropriate treatment options for the patient are guided by the outcome of the caries risk assessment. The child's behavior is another overriding consideration as it determines how the treatment can be rendered. Information obtained through careful evaluation of each area results in a treatment plan specifically designed for each child's circumstance.

The use of tenoten and tenoten (pediatric formulation) as a drug for premedication in adults and children during outpatients dentist visit.

The use of tenoten and tenoten (pediatric formulation) for premedication in adults and children before dental treatment reduces patient anxiety; the effect is comparable with that of classical anxiolytics and is not accompanied by side effects. These preparations can be recommended for wide use in dentistry.

Medical Management of Dental Anxiety.

The use of medical management techniques for the management of anxiety is fundamental to the practice of dentistry. Around 7% of the population are likely to need these techniques for general dental care and a higher proportion for more invasive treatment such as oral surgery. This paper highlights the current expectation of effective and safe practice of conscious sedation techniques in light of recent updated guidance from several UK institutions.

Shared decision-making (SDM) in dentistry: A concise narrative review.

OBJECTIVE: The aim of this review was to evaluate the implementation of shared decision-making (SDM) in dentistry and the roles of informed consent and patient decision-making aids (PDAs) as part of this process. MATERIALS AND METHODS: A review of pertinent literature was performed using PubMed and MEDLINE to determine the current position of the application of SDM in dentistry and the influence of informed consent and PDAs on this process. RESULTS: Limited number of published studies on the implementation of SDM in dental practice is available. These studies demonstrated that SDM is influenced by many factors. Informed consent intertwines with the SDM process and begins with providing high quality information to patients and employing PDAs. PDAs have been developed for some dental fields to facilitate the SDM process. CONCLUSIONS: SDM is applied in dentistry and is influenced by many factors. Informed consent is an important part of this process. PDAs in more dental fields need to be further developed, in order to ensure a satisfactory integration of patients in the SDM process.

Influence of lavender oil inhalation on vital signs and anxiety: A randomized clinical trial.

OBJECTIVE: To investigate the effectiveness of lavender oil (Lavandula angustifolia Mill) inhalation on anxiety, mood, and vital signs (blood pressure, respiratory rate, heart rate, and saturation) of patients undergoing oral surgery. Vital signs were considered as primary outcome measures. Paired anxiety tests were used as secondary outcome measures. METHODS: Patients who had dental anxiety according to the Dental Anxiety Questionnaire (DAQ) were enrolled in the study. One hundred twenty-six patients who were undergoing wisdom tooth removal under local anaesthesia were randomly assigned to the lavender oil and control groups. Paired anxiety tests (Modified Dental Anxiety Scale and State-Trait Anxiety Inventory-State Scale were performed. Vital signs were noted pre-, intra-, and post-operatively. Visual analogue scale (VAS) results were assessed. The patients' degree of satisfaction was noted. RESULTS: Pre-operative anxiety levels were similar in both groups. Significant changes in blood pressure were observed in the lavender oil group post-operatively (p < .05). Most (79.4%) of the patients in the lavender oil group enjoyed the scent, 89.68% were satisfied with their experience, and 97.62% of the patients stated that they would prefer the same protocol when needed. CONCLUSION: Inhalation of lavender oil, which is one of the most powerful anxiolytic essential oils, reduces peri-operative anxiety and can be prospectively considered in future studies for its potential sedative characteristics in patients undergoing surgical procedures under local anaesthesia. TRIAL REGISTRATION NUMBER: NCT03722771 (Influence of Lavender Oil on Vital Signs in Oral Surgery Patients) https://clinicaltrials.gov/ct2/show/NCT03722771.