Comparisons of Varying Dosages of Chloral Hydrate-Hydroxyzine with and without Meperidine for Managing Challenging Pediatric Dental Behavior: A Retrospective study of 35 years of Sedation Experiences.

PURPOSE: This retrospective study compares the efficacy and safety of variable dosing of Chloral Hydrate - Hydroxyzine with and without Meperidine (Mep)for managing varying levels of anxiety and uncooperative behavior of young pediatric dental patients over a 35-year period. STUDY DESIGN: Reviews of the sedation logs of 2,610 children, 3-7 years were compared in search of what dosing proves safe and effective for differing levels of challenging behavior. Variable dosing of CH with and without Mep were judged using a pragmatic approach which defined sedation success as optimal, adequate, inadequate, or over-dosage using oneway analysis of variance. Descriptive analyses of behavior and physiologic assessment was included with regard to the extent to which physical restraint occurred to control interfering behavior. Arousal levels requiring stimulation, oxygen desaturation, and adverse reactions were included as indications of safety. RESULTS: Where Mep was used, success rates were consistently higher; need for higher-end dosing of CH was not found beneficial when Mep was included. Significantly less need for physical restraint accompanied the addition of Mep. CONCLUSIONS: There appears to be strong basis for the safety and efficacy of the use of CH-H-Mep in combination at lower dosing than historically used. Addition of Mep was observed to enhance sedations, permit lower CH dosing, lessen or eliminate the need for physical restraint and adverse reactions.

Retrospective Comparisons of the Efficacy and Safety of Variable dosing of Midazolam with and without Meperidine for Management of Varying Levels of Anxiety of Pediatric Dental Patients: 35 years of Sedation Experience.

PURPOSE: This retrospective study compares the efficacy and safety of variable dosing of Midazolam (Mid) with and without Meperidine (Mep) combinations for managing varying levels of anxiety and uncooperative behavior of young pediatric dental patients over a thirty-five-year period. STUDY DESIGN: Reviews of the sedation logs of 1,785 sedation visits are compared with emphasis on what dosing proves both safe and effective for differing levels of challenging pediatric behavior. Variable dosing of midazolam with and without meperidine which spanned low-end, mid-range, and upper-end were judged making use of a pragmatic approach which defined sedation success as optimal, adequate, inadequate, or over-dosage. Behavioral and physiologic assessment was included with attention to readily observable analysis of the extent to which need for physical restraint occurred to control interfering behavior. Assessment of arousal levels requiring stimulation along with the frequency of alterations in oxygen de-saturation and adverse reactions were included as indications of safety. RESULTS: Where Mep was used, success rates were consistently higher; working times were significantly prolonged and greater control was provided to avoid adverse reactions by virtue of reversal capability for both agents. CONCLUSIONS: Predictability and working time of Midazolam was enhanced by combination with narcotic for all levels of patient anxiety. Dosages of 0.7-1.0 mg/kg Mid combined with 1.0-1.5 mg/kg Mep offers the most effective and safe results to overcome need for restraint for moderate and severe levels of anxiety, respectively.

Behavioral management strategies for young pediatric dental patients with disabilities.

Disruptive behaviors, particularly from those lacking in cooperative ability, often are prompted by the need to protest an unpleasant situation and the impulse to protect oneself from perceived danger. Such behaviors, depending on the patient's age and cognitive ability, should be seen as an attempt of the child to cope with a frightening situation. The inherent challenge for both clinician and parent is to avoid unpleasant and unproductive confrontations from the outset, and to create an environment to facilitate the child's ability to accept care, protect the child's self-esteem, foster a positive outlook toward care, and enhance the work quality of dental personnel. In order to use safely any of the modalities for sedation considered [table: see text] in this paper, it is imperative that the clinician receive adequate clinical instruction before private clinical use is attempted.

Managing behavior of precooperative children.

Disruptive behaviors, particularly from those lacking in cooperative ability, often are prompted by the need to protest an unpleasant situation and the impulse to protect oneself from perceived danger. Such behaviors, depending on the patient's age and cognitive ability, should be seen as an attempt of the child to cope with a frightening situation. The inherent challenge for both clinician and parent is to avoid unpleasant and unproductive confrontations from the outset and to create an environment to facilitate the child's ability to ultimately accept care, protect the child's self-esteem, foster a positive attitude toward care, and enhance the work quality and efficiency of the dental personnel. Use of behavioral management strategies that permit accomplishing these objectives have been described. The reader is encouraged to pursue further knowledge and expertise to make best use of nonaversive strategies for management of the precooperative child.

Management of the difficult child: a survey of pediatric dentists' use of restraints, sedation and general anesthesia.

The findings of a 1988 survey of 616 pediatric dentists' attitudes and utilization of non-pharmacologic and pharmacologic strategies for treating the difficult pediatric patient are described. Wide variations appear to exist with regard to the use of restraints and aversive techniques, parent presence in the operatory, use of sedation, and general anesthesia. Variables including practice location, caries prevalence, patient populations, individual training experiences and skills, and liability costs clearly have an impact on pediatric dentists perception of the appropriateness of various modalities and their choice of application. There appear to be more concerns regarding the issue of informed consent, the appropriateness of hand-over-mouth, particularly HOMAR, and the use and overuse of sedation and general anesthesia. In the area of risk management, although many report high proficiency and comfort levels in their ability to recognize and manage in-office medical emergencies, others using various forms of in-office sedation, however, report having minimal emergency and monitoring equipment or training.

The challenge of fearful and phobic children.

Many children are fearful of going to the dentist. Professionals have the opportunity to avoid causing long-term anxiety disorders by providing a safe environment and offering children opportunities to overcome their normal childhood fears during early visits. It is more important to focus on a positive interaction between dentist and child rather than the completion of the dental procedure.

The effects of nitrous oxide on anxious young pediatric patients across sequential visits: a double-blind study.

Nitrous oxide has acquired widespread use as a tool for managing young dentally anxious children. Clinical impressions have suggested it eliminates uncooperative behavior while alleviating anxiety and facilitating coping skills. Data to support these claims documenting the effects of nitrous oxide across sequential visits has not previously been presented. Research which attempts to clarify the impact of a particular intervention on anxiety reduction, the development of coping skills, or the modification of patient attitudes toward care can anticipate numerous and complex methodological obstacles. Nevertheless, it seems important that longitudinal approaches which examine the anxiety process prospectively are necessary to clarify the immediate and long-term consequences of proposed anxiety management strategies. Further work seems particularly urgent to develop improved methods, in which to assess and measure childhood dental anxiety and the impact of strategies directed at its reduction. Further study which addresses these issues is needed to guide best the effective and appropriate use of nitrous oxide for the pediatric patient.

Comparison of chloral hydrate-hydroxyzine with and without meperidine for management of the difficult pediatric patient.

This study attempted to examine the impact of low doses of meperidine on the effectiveness of two doses of CH for management of highly resistive young pediatric dental patients. The results suggest patient manageability was enhanced by the addition of oral meperidine. As an alternative to a parenteral technique or general anesthetic, the clinician may wish to consider this regimen after having experienced failure of CH either alone, or in combination with an antiemetic, to produce an adequate level of sedation. The extent to which application of physical restraint is considered necessary or acceptable should be taken into account, when evaluating the need for a regimen of medication. If the purpose of selecting a sedative technique is to accomplish lengthy treatment without harsh restraint, the degree to which restraint is needed no doubt reflects on the adequacy of the sedative regimen. The addition of meperidine was found to reduce significantly the need for persistent harsh physical restraint, to allow treatment of the refractory young child. While the brief application of harsh restraint measures may be warranted and justifiable in emergency medical situations, it seems unwise to make use of harsh restraint for lengthy elective dental procedures. Given the extent to which many adults report negative childhood dental experiences, avoidance of the use of aversive measures seems desirable. Of the cases receiving meperidine, 76.3 percent were treated successfully (no need for persistent restraint), compared to the successful treatment of only 30.7 percent of the patients sedated without meperidine.(ABSTRACT TRUNCATED AT 250 WORDS)

Management of the refractory young child with chloral hydrate: dosage selection.

Chloral hydrate is often selected for its wide range of safety, yet concerns are increasingly raised about its frequent failure to provide adequate levels of sedation while using the recommended hypnotic dosage. This paper discusses the implications of these weaknesses in a pedodontic context.

Management of the refractory young child with chloral hydrate: dosage selection.

Chloral hydrate is often selected for its wide range of safety, yet concerns are increasingly raised about its frequent failure to provide adequate levels of sedation while using the recommended hypnotic dosage. This paper discusses the implications of these weaknesses in a pedodontic context.