Temperament as a Predictor of Nitrous Oxide Inhalation Sedation Success.

Little is known about implications of temperament for children who receive nitrous oxide inhalation sedation (N2O/O2) for dental care. The aim of this study was to investigate whether child temperament is associated with success in N2O/O2. Child-caregiver dyads were enrolled from patients aged 36-95 months receiving dental care with N2O/O2 at a university-based pediatric dental clinic. To assess child temperament, 48 caregivers completed the Children's Behavior Questionnaire Short Form. Patient behavior was abstracted from Frankl scores recorded in the patient's chart. The overall behavioral failure rate was 15% (n = 7/48). There was no significant difference in sedation outcome associated with sex, health, insurance status, or complexity of treatment provided. Sedation outcome was significantly associated with the broad temperament domain of Effortful Control and its subscales Attentional Focusing and Inhibitory Control. The Negative Affectivity subscales of Frustration, Sadness, and Soothability and the Extraversion/Surgency subscales Activity and Impulsivity were also significantly associated with sedation outcome. The results of this study suggest that Effortful Control is associated with behavior during dental treatment with N2O/O2. The subscales of Attention Focusing, Inhibitory Control, Frustration, Fear, Sadness, Soothability, Activity, and Impulsivity may also be important determinants of child behavior during dental treatment.

The Effect of Temperament on Outcomes of Opioid and Non-Opioid Pediatric Dental Sedation.

Purpose: To assess oral sedation success using midazolam and hydroxyzine with and without meperidine, and to assess the relationship between child temperament and sedation outcomes. Methods: This study recruited children between the ages of 36 and 95 months who were randomly assigned to receive dental treatment with an oral sedation regimen of midazolam (0.5 mg/kg) and hydroxyzine (1.0 mg/kg) with or without meperidine (1.5 mg/kg). Data were collected from the treatment log and electronic health records. Parents completed the Child Behavior Questionnaire Short Form (CBQ-SF) to assess temperament. Results: The study included 37 participants. The overall treatment success rate was 54 percent. There were no significant differences in sedation outcome with age, sex, insurance status, sedation regimen, isolation method or duration of procedure. Children with high pre-operative Frankl behavioral ratings were more likely to have a successful sedation outcome (P <0.01). Children who displayed high soothability experienced higher rates of success (P =0.04), which was more pronounced in the non-opioid group (P <0.01). Conclusion: The study showed low rates of success for a relatively small sample size. There was no difference in sedation success between the opioid group and non-opioid group. However, pre-procedure behavior and temperament characteristic of sooth- ability may warrant more exploration as predictors of sedation success.

Opioid and Multi-Drug Pediatric Dental Sedation: A Narrative Review.

Pharmacological behavior guidance has long been a mainstay of pediatric dental care. Behavioral limitations of very young children and dental fear in adolescents and children with special health care needs have made sedation and general anesthesia important to quality care delivery for these populations. The purposes of this review are to provide a broad perspective on the historical and contemporary use of sedation in pediatric dentistry, summarize available data on the safety and efficacy of opioid and multi-drug moderate sedation protocols, and consider the growing role of minimal intervention dentistry and the importance of patient and medication selection.

Comparison of Procedures, Time and Fees Associated with Procedural Sedation and General Anesthesia in a Pediatric Dentistry Residency Program.

Purpose: To compare dental procedures, time, success rates and fees associated with pediatric dental treatment using oral moderate sedation (SED) and general anesthesia (GA) in a pediatric dentistry residency program. Methods: This retrospective chart review included a convenience sample of 50 patients between 2016 and 2017 who received SED and 50 patients who received GA for dental treatment. Healthy 24- to 71-month old Medicaid-insured patients who received restorative dental treatment were included. Treatment time and procedure codes were abstracted from the dental record. Fees were calculated based upon the pharmacologic modality utilized to complete each patient's treatment plan. Results: On average, GA patients were younger (P <0.001) and received a greater number (12.8 versus 5.6; P <0.001) and complexity of dental procedures than those in the SED group ( P <0.001). Pharmacologic fees associated with GA were higher ($653 for GA, $137 for SED, P <0.001). The overall SED success rate was 66 percent and significantly differed by the number of visits required, with the highest success rate (74 percent) at the second visit (P =0.011). Conclusions: Procedures performed, time, success rates and associated fees differed significantly between SED and GA. These characteristics should be considered when planning treatment for pediatric patients.

Comparison of Pediatric Dentistry Under General Anesthesia in a Surgery Center vs a Hospital.

OBJECTIVE: Pediatric patients who undergo general anesthesia (GA) for dentistry may be treated in different venues. This retrospective study compared patients treated in an ambulatory surgery center (ASC) to those treated in a hospital operating room (H-OR). The 2-venue model was also compared with a historical hospital-only model. METHODS: Twelve months of data were collected via records review: patient demographics, American Society of Anesthesiology (ASA) classification, and medical comorbidities. Data from patients treated at the H-OR 10 years prior were referenced for comparison. RESULTS: Between July 2017 and June 2018, 1148 patients were treated: 635 at the ASC and 513 at the H-OR. The most common age range for both venues was 3 to 8 years. Of all the ASC patients, 78% were ASA I, while 48% of H-OR patients were ASA III (P < .001). The number of patients treated with the 2-venue model represented a 240% annual increase compared with those treated historically using the hospital-only model. CONCLUSION: Because of differences in patient medical comorbidities, both the ASC and H-OR are needed to adequately address the needs of pediatric dental patients who require GA. Treating healthy patients in an ASC also creates increased capacity in the H-OR to better accommodate those with higher medical acuity.

Cardiovascular Safety and Hemostatic Efficacy of Topical Epinephrine in Children Receiving Zirconia Crowns.

OBJECTIVE: The primary aim of this study was to determine the cardiovascular safety of topical racemic epinephrine pellets by measuring heart rate, systolic blood pressure, diastolic blood pressure, and mean arterial pressure in children receiving dental care under general anesthesia. The secondary aim was to assess clinical efficacy by measuring time to reach adequate hemostasis. METHODS: For this pilot study utilizing a split-mouth randomized design, 13 patients requiring prefabricated zirconia crowns on both primary maxillary first molars were recruited. Patients received continuous infusions of propofol and remifentanil with 50-70% inhaled nitrous oxide and oxygen. After randomization and tooth preparation, either saline pellets (control) or racemic epinephrine pellets (experimental) were applied directly to gingival tissue. Vital signs were recorded for 5 minutes. The procedure was repeated on the contralateral side using the alternative (control or experimental) treatment. RESULTS: Topical racemic epinephrine compared to saline produced a significantly larger decrease in mean diastolic blood pressure (-11.1% vs -3.9%; P < .01) and mean arterial pressure (-8.1% vs -2.1%; P < .01), although all noted decreases in cardiovascular variables were clinically insignificant. All experimental treatment teeth achieved adequate hemostasis after 2.2 minutes. Only 5 of the 13 control treatment teeth achieved adequate hemostasis during the 5-minute observation period (1.6 vs 4.2 minutes; P = .01). CONCLUSION: Overall, we conclude that use of topical racemic epinephrine pellets did not result in adverse cardiovascular effects and hemostasis was reached more quickly and predictably compared to saline pellets.

Teaching and utilization of silver diamine fluoride and Hall-style crowns in US pediatric dentistry residency programs.

BACKGROUND: Nonsurgical caries management, particularly silver diamine fluoride (SDF) and Hall-style crowns, present alternative options for populations that have barriers to traditional treatment. The authors aimed to assess changes in the teaching and utilization of these modalities in pediatric dental residency programs. METHODS: The authors e-mailed a 29-question electronic survey regarding the utilization and teaching of nonsurgical caries management agents to US pediatric dentistry residency program directors. Data were compared with results from a similar survey conducted in 2015 to analyze trends, report protocols, barriers for utilization, and possible reasons for changes. RESULTS: Respondents from 82 programs completed the surveys (89% response rate). Although only 26% of respondents reported using SDF in 2015, 100% reported its utilization in 2020 (P < .001). The Hall-style crown technique is taught didactically in 90% of programs, and 69.5% of respondents use it at least sporadically in their clinics. Long wait times for the operating room (4 weeks-14 months) and sedation (1 week-12 months) motivate increased utilization of SDF, interim therapeutic restorations, and Hall-style crowns. Guidelines supporting off-label utilization of SDF have also resulted in its increased utilization. CONCLUSIONS: US pediatric residency programs have universally adopted SDF for caries arrest in the primary dentition, and this trend seems to extend to other nonsurgical caries management agents. These changes are likely driven by diverse barriers to delivery of traditional restorative care. PRACTICAL IMPLICATIONS: The rapid increases in teaching and utilization of minimal intervention techniques provide clinicians with more options for caries management in patients with barriers to traditional treatment.

Oral Health and Oral Health-Related Quality of Life in Children With Obstructive Sleep Apnea.

STUDY OBJECTIVES: This aim of this study was to evaluate oral health and oral health-related quality of life (OHRQoL) in children with obstructive sleep apnea (OSA). METHODS: This cross-sectional study involved 31 children who had baseline polysomnography studies and in whom a diagnosis of OSA was made by a sleep physician. They were evaluated against 36 control patients who, based on parent responses to the Pediatric Sleep Questionnaire, were at very low risk for having sleep problems. The mean age of the cohort was 12.3 ± 2.7 years. The oral health status was examined clinically and recorded using caries and periodontal indices. OHRQoL was measured using the Child Oral Health Impact Profile (COHIP) questionnaires. RESULTS: Children with OSA had significantly worsened oral health compared to control patients as evidenced by more caries (15.2 and 3.2, respectively; P < .001) and more periodontitis. Periodontitis severity was measured by the presence of bleeding on probing, (87% versus 30%, P < .001) and higher number of sites with abnormally deep periodontal probing depths (2.7 versus 0.3, P < .001). The COHIP scores were significantly higher among children with OSA compared to control patients, (29.7 versus 11.8, P < .001) consistent with poorer OHRQoL. CONCLUSIONS: This study suggests that in children OSA may have a significant association with poorer oral health when compared to control patients without sleep problems, and that their oral health status may have a negative effect on their quality of life. Increased awareness regarding the oral health effects of sleep-disordered breathing in the medical and dental community is needed.

Children with Autism Spectrum Disorder Are Able to Maintain Dental Skills: A Two-Year Case Review of Desensitization Treatment.

Purpose: The purposes of this study of children with autism spectrum disorder (ASD), who had successfully accepted a dental examination seated in a dental chair following desensitization interventions, were to: (1) determine if ability to accept an examination was maintained two years following initial success; (2) quantify new dental skills acquired; and (3) analyze the use of advanced behavior guidance techniques. Methods: This retrospective two-year case series included 138 ASD children. Data were obtained from dental records. Descriptive statistics were calculated, and Fisher's exact test was used for comparisons of interest. Results: Most children (92 percent) maintained the ability to receive minimum threshold examinations once the initial exam had been achieved. New basic dental skills attained by most children included receiving toothbrush prophylaxis (83 percent) and accepting fluoride varnish (77 percent). Few children required oral sedation or protective stabilization, but 22 percent received general anesthesia. Conclusions: Most children with autism spectrum disorder who learned to accept an examination maintained that skill over time, and many accepted toothbrush prophylaxis and fluoride varnish. Sensory-invasive skills, such as radiographs and rubber cup prophylaxis, were acquired with lower frequency. Therefore, when treating ASD patients, it is important to consider that some will require advanced behavior guidance techniques. (Pediatr Dent 2019;41(5):397-403).

A Retrospective Study of Dosing Weight and Outcomes for One Pediatric Dental Sedation Regimen.

Purpose: The purpose of this study was to assess the use of a dosing scalar for association with the success of procedural sedation in pediatric dentistry. Methods: This cross-sectional, retrospective study assessed healthy two- to 12-year-olds who received an elixir of midazolam (0.3 mg/kg), meperidine (1.5 mg/kg), and hydroxyzine (1.0 mg/kg). The scaled body weight (SBW) for each patient was determined using the 50th percentile weight-for-age from the 2000 Centers for Disease Control and Prevention (CDC) growth chart. Children under the 50th percentile were dosed at their actual weight. Children weighing over the 50th percentile received a dose that was reduced to the 50th percentile weight-for-age. Statistical analysis evaluated sedation success, measured by the Houpt scale. Lean body weight (LBW) and ideal body weight (IBW) were calculated to compare SBW with other available dosing scalars. Results: The sample consisted of 427 children. The success was 73.8 percent. There was no significant difference in sedation success by dose delivered. The calculated LBW and IBW were significantly greater than the SBW (P<.001, P<.001). Conclusions: Sedation success was not affected by use of a scalar that reduced dosing weight to the 2000 CDC growth chart's 50th percentile weight-for-age.

Assessment of the Location of the Mandibular Lingula in Pediatric Patients Using Cone Beam Computed Tomography Images.

Purpose: The purpose of this study was to determine the position of the mandibular lingula in a sample of cone beam computed tomography (CBCT) images taken on pediatric patients.Methods: A sample of 280 outpatient CBCT (i-CAT) scans (153 males and 127 females) were divided into three age groups: six to nine years (n=103), 10 to 13 years (n=103), and 14 to 18 years (n=74). The position of the lingula was determined relative to the anterior and posterior border of the ramus, mandibular notch, inferior border of the mandible, and mandibular plane. The mandibular angle was also recorded. In Vivo5 software was used to assess the images.Results: The average distance for all positional measurements was significantly greater in 14- to 18-year-old adolescents when compared with six- to nine-year-old children. In the oldest age group, the mandibular angle was significantly more acute. Significant differences in distances were noted bilaterally across all age groups in boys and girls for distance from lingula to mandibular notch, to inferior border mandible and to occlusal plane, while for distance lingula to posterior border of ramus it was only for boys.Conclusions: As children age, the mandible increases in all dimensions, except for the distance from the anterior border to the lingula. Small differences in the position of the mandibular lingula exist between boys and girls. These findings have implications for administering an inferior alveolar nerve block in children.

Predicting successful dental examinations for children with autism spectrum disorder in the context of a dental desensitization program.

BACKGROUND: The authors evaluated the effectiveness of a dental desensitization program for children with autism spectrum disorder (ASD) and determined characteristics associated with a successful dental examination. METHODS: The authors performed a retrospective review of clinical behavioral data and previsit questionnaires for 168 children with ASD who attended a university-based dental desensitization program. Data elements included demographic, treatment, and behavioral characteristics. The primary outcome was receiving a minimal threshold examination (MTE) while seated in a dental chair. RESULTS: An MTE was achieved for 77.4% of all children within 1 to 2 visits and 87.5% in 5 visits or less. Several factors predicted a successful dental examination: ability to be involved in group activities (relative risk [RR], 1.18; P = .02), ability to communicate verbally (RR, 1.17; P < .01), understanding of most language (RR, 1.14; P = .02), moderate versus severe caregiver-rated ASD severity (RR, 1.24; P = .04), and ability to dress self (RR, 1.27; P = .04). CONCLUSIONS: Desensitization was effective in achieving an MTE for most children. Those with characteristics consistent of a milder presentation of ASD were more likely to be successful. PRACTICAL IMPLICATIONS: Desensitization can be a successful approach to providing dental care for children with ASD.

Caretakers' Self-Selected Oral Health Goals: Self-Efficacy, Perceived Compliance, and Effect on Recall Attendance.

PURPOSE: The purpose of this study was to describe caretakers' self-selected pediatric oral health goals, self-reported compliance, perceived self-efficacy, and perceived barriers to goal accomplishment. The effect of self-management plans on recall attendance was also evaluated. METHODS: Fifty caretaker-patient pairs who presented for examinations at a university pediatric dental clinic were assigned to an intervention group. Fifty age-matched subjects were assigned to the comparison group. At baseline both groups completed a demographic survey. The intervention group developed a self-management plan and selected oral health goals. Follow-up surveys were administered to the intervention group two weeks and six months later. RESULTS: The most frequently selected oral-health goals were brush twice daily (21 percent) and toothbrush before bed (17 percent). At the two-week follow-up, 39 percent of contacted caretakers recalled their chosen goals correctly, compared to 26 percent at six months. Approximately half of the participants in both groups attended the six-month follow-up visit. The difference in recall attendance between intervention and comparison group was not significant (P=0.80). CONCLUSIONS: Caretakers most frequently selected goals that were associated with toothbrushing. They initially reported high confidence levels; however, recall and compliance with self-selected oral-health goals decreased significantly over the course of six months.

Parent, Dentist, and Independent Rater Assessment of Child Distress During Preventive Dental Visits.

PURPOSE: Although typically not painful, preventive dental care can be distressing to young children. A greater understanding of how adults perceive child distress may enable clinicians to improve the patient/parent experience through alignment of values and facilitation of shared decision-making. The purpose of this study was to examine the association between parent, dentist, and independent observer (IO) ratings of child distress during preventive dental procedures. METHODS: Sixty-five children younger than three years were seen for preventive dental care at a university dental clinic. Parents, dentists, and an IO rated intensity of child distress during four phases of the dental visit: (1) pre-exam; (2) positioning; (3) prophylaxis/exam/fluoride; and (4) post-exam. RESULTS: The average age of the children was 24.4 months old (±7.2 SD). The prophylaxis/exam/fluoride phase was judged to be most distress inducing. Mean distress ratings for this phase were: 2.30 (parents); 2.47 (dentists); and 3.08 (IO), which was statistically significant (P=.04). The IO ratings were significantly different from parents (for three phases) and dentists (for one phase); no statistically significant differences were noted between parent and dentist ratings for any phase. CONCLUSIONS: There was a strong agreement between parents' and dentists' ratings of child distress during preventive dental procedures.

Silver Diamine Fluoride in Pediatric Dentistry Training Programs: Survey of Graduate Program Directors.

PURPOSE: The purpose of this study was to investigate practice, teaching, and perceived barriers to the use of silver diamine fluoride and other caries control agents in U.S. pediatric dentistry residency programs. METHODS: A 14-question survey regarding use and teaching of caries control agents was sent via email to residency program directors in 2015. Survey participants responded, using a web-based survey tool, by completing a paper and pencil survey instrument, or by interview. RESULTS: Surveys were completed by 74 directors or associate directors (87 percent adjusted response rate). More than a quarter (25.7 percent) reported use of silver diamine fluoride, with 68.9 percent expecting to increase use. The use of silver diamine fluoride was not associated with region or program type. Programs reported commonly used caries control agents of fluoride varnish (100 percent), acidulated phosphate fluoride foam (48.6 percent), silver nitrate (9.5 percent), and povidone iodine (1.3 percent). Most felt silver diamine fluoride should be used only with high-risk patients (89.2 percent), and the majority agreed it could be used in primary and permanent teeth. The most frequently reported barrier to use of silver diamine fluoride was parental acceptance (91.8 percent). CONCLUSIONS: Silver diamine fluoride is being rapidly adopted in graduate pediatric dentistry training programs, with the majority expecting to incorporate it into their teaching clinics and curricula.

Dental stories for children with autism.

PURPOSE: To investigate caregivers' preference regarding dental stories to prepare children with autism for dental visits. METHODS: Caregivers of children with autism were allowed use of dental stories available via different media (paper, tablet computer, computer) and image types (comics or drawings, photographs, video). Caregivers completed pre- and postintervention surveys. Fisher's exact tests were used to determine associations between predictive factors and preferences. RESULTS: Forty initial and 16 follow-up surveys were completed. Subjects were primarily male (85%). Mean child age was 6.7 years. Nine (64%) caregivers found the dental story useful for themselves and their child. Two (14%) caregivers found the aid only helpful for themselves. Preferred media type was associated with language understanding (p = .038) and home media preference (p = .002). CONCLUSIONS: Practitioners should consider using dental stories to help prepare families and children for dental visits. Individual preferences for dental stories vary; using prior history can aid in selection.

Pediatric dental sedation: challenges and opportunities.

High levels of dental caries, challenging child behavior, and parent expectations support a need for sedation in pediatric dentistry. This paper reviews modern developments in pediatric sedation with a focus on implementing techniques to enhance success and patient safety. In recent years, sedation for dental procedures has been implicated in a disproportionate number of cases that resulted in death or permanent neurologic damage. The youngest children and those with more complicated medical backgrounds appear to be at greatest risk. To reduce complications, practitioners and regulatory bodies have supported a renewed focus on health care quality and safety. Implementation of high fidelity simulation training and improvements in patient monitoring, including end-tidal carbon dioxide, are becoming recognized as a new standard for sedated patients in dental offices and health care facilities. Safe and appropriate case selection and appropriate dosing for overweight children is also paramount. Oral sedation has been the mainstay of pediatric dental sedation; however, today practitioners are administering modern drugs in new ways with high levels of success. Employing contemporary transmucosal administration devices increases patient acceptance and sedation predictability. While recently there have been many positive developments in sedation technology, it is now thought that medications used in sedation and anesthesia may have adverse effects on the developing brain. The evidence for this is not definitive, but we suggest that practitioners recognize this developing area and counsel patients accordingly. Finally, there is a clear trend of increased use of ambulatory anesthesia services for pediatric dentistry. Today, parents and practitioners have become accustomed to children receiving general anesthesia in the outpatient setting. As a result of these changes, it is possible that dental providers will abandon the practice of personally administering large amounts of sedation to patients, and focus instead on careful case selection for lighter in-office sedation techniques.