The physiological effects of supplemental oxygen versus nitrous oxide/oxygen during conscious sedation of pediatric dental patients.

PURPOSE: This study was performed to compare the effects of nitrous oxide/oxygen (N2O/O2) versus oxygen (O2) as adjuncts to an oral narcotic regimen for pediatric conscious sedation. METHODS: Using a randomized double-blind crossover design, 19 children (mean age 41 +/- 8.6 months) were sedated with chloral hydrate (50 mg/kg), meperidine (1.5 mg/kg) and hydroxyzine pamoate (25 mg) for two appointments. Patients were assigned randomly to receive 100% O2 at one visit and 50% N2O/O2 at the other. Physiologic parameters were measured in five-minute intervals, including respiratory rate, pulse rate (PR), oxyhemoglobin saturation (SpO2) and end-tidal carbon dioxide. Data analyses focused on true desaturations and apnea, level of sedation and sedation outcomes. RESULTS: There were no differences in PR, SpO2 and risk of desaturation between the inhalation agents. The level of sedation was deeper and the sedation outcomes were better in the N2O/O2 group. CONCLUSION: N2O/O2 deepened the sedation while improving its success with minimal alteration in physiologic parameters.

Mercury exposure due to environmental factors and amalgam restorations in a sample of North Carolina children.

PURPOSE: Dental amalgam restorations provide a potential source for mercury (Hg) exposure in children. This study explored the possibility that Hg levels in dentin of exfoliated primary maxillary canines could detect cumulative Hg exposure from amalgam restorations in a sample of North Carolina children. METHODS: Twenty-seven exfoliated maxillary canines from 3.3 children, without restorations or caries, were assayed for dentin Hg concentration ([Hg]). Urine samples were obtained from 21 subjects and assayed for [Hg] and diet surveys for seafood ingestion were completed for 26 subjects. A surface/month exposure index (SMEI) was compiled from dental records to quantify each child's cumulative exposure to amalgam restorations. RESULTS: Results showed that dentin [Hg] ranged from undetectable levels to 15.7 ppm with a mean of 3.7 ppm. The SMEI scores ranged from 0-638 with a mean of 95. Ten subjects had low SMEI scores of 0-3, nine had scores 4-100, and eight had scores higher than 100. No statistical correlation was found for SMEI scores and dentin [Hg]. Urine Hg levels were found to be negligible and no relationship was found between urine [Hg] and reported ingestion of seafood or SMEI scores. CONCLUSIONS: Hg exposure in this sample of children was low and additional exposure from amalgam restorations could not be detected by the methods used in this study.

The effect of supplemental oxygen on apnea and oxygen saturation during pediatric conscious sedation.

PURPOSE: This study compared the effect of supplemental oxygen (O2) on pediatric patients' apnea status and oxyhemoglobin saturation during: 1) conscious sedation for dental procedures and 2) the recovery period following sedation. METHODS: Fourteen child patients (mean age 42 months) sedated with 50 mg/Kg chloral hydrate, 25 mg hydroxyzine pamoate, and 1.5 mg/Kg meperidine were treated for two separate appointments. The patients received supplemental O2 via nasal cannulae at random at one of the two appointments. Following the operative period, all patients were monitored sitting upright for an additional 15 min. RESULTS: Intraoperative results showed that the risk of apnea was 39% (11/28), with apneic events distributed equally between O2 and non-O2 supplemented sedations. The overall risk of desaturation was 29% (8/28). Mean SpO2 was always elevated with O2 supplementation and the mean difference in O2 versus non-O2 was statistically significant. The risk of apnea in the postoperative period was 7% (1/14) for both the non-O2 and O2-supplemented patients. The risk of desaturation in the postoperative period was 11% (3/28) with one desaturation in a non-O2 and two desaturations in O2-supplemented patients. CONCLUSION: We conclude that intraoperative O2 supplementation prevents desaturations even in the presence of apnea during pediatric conscious sedation.

A comparison of conventional versus electronic monitoring of sedated pediatric dental patients.

The first purpose of this study was to compare traditional monitoring methods to electronic instruments for monitoring physiologic parameters during conscious sedation of pediatric dental patients. Traditional methods included careful visual assessment of skin color, airway patency and chest movements, and auscultation of breath and heart sounds using a precordial stethoscope; electronic instruments included the capnograph and pulse oximeter. The second purpose of the study was to examine the potential of the capnograph to provide more advanced warning than the pulse oximeter for respiratory compromise. Thirty-nine children (mean age 39 months) received an oral sedative regimen of chloral hydrate, hydroxyzine pamoate, and meperidine and all were supplemented with 100% oxygen via nasal cannula throughout their sedations. One investigator used traditional monitoring and the other used electronic--both monitored simultaneously while being shielded (blinded) from each other. Electronic monitoring yielded a false alert rate of 88% compared with 73% for traditional monitoring. Ten confirmed episodes of respiratory compromise were identified electronically and only three were identified by traditional monitoring. All of the 10 confirmed respiratory compromise episodes were detected by capnography; none were detected by oximetry. During these 39 pediatric sedations using a narcotic drug regimen and 100% oxygen supplementation, there were no true desaturations.

Diagnosing and treating common oral pathologies.

When the physician is confronted with an oral pathologic condition in a child, the adage "common things happen commonly" should be applied. Congenital lesions such as palatal and alveolar cysts occur in almost 50% of newborns. Developmental conditions such as Fordyce granules and retrocuspid papillae are found in most children. Localized soft-tissue enlargements commonly seen in young children include the parulis, mucocele, papilloma, and inflammatory gingival tumors. In addition, soft-tissue pathologies and discomfort associated with herpesvirus infections or recurrent aphthous ulcerations often present as a chief complaint. The physician's knowledge and treatment recommendations for common oral pathologies should be an integral component to the overall medical management of infants, children, and adolescents.

Conscious sedation of pediatric dental patients: an investigation of chloral hydrate, hydroxyzine pamoate, and meperidine vs. chloral hydrate and hydroxyzine pamoate.

This study evaluated two oral sedative regimens for the conscious sedation of pediatric dental patients (mean age 37.0 months) unmanageable by traditional behavior management techniques. Regimen A included chloral hydrate (Noctec--E.R. Squibb and Sons, Princeton, NJ) at 50 mg/kg with 25 mg hydroxyzine pamoate (Vistaril--Pfizer Laboratories, New York, NY), plus meperidine (Demerol--Winthrop-Breon, New York, NY) at 1.5 mg/kg. Regimen B included chloral hydrate at 50 mg/kg with 25 mg hydroxyzine pamoate. In a crossover research design, 10 patients were assigned randomly to receive one regimen, to be followed by the alternative regimen during the second appointment. The primary purpose of this study was to determine if meperidine would improve patient behavior, and increase the prevalence of respiratory compromise. A secondary purpose of the study was to develop an objective method to assess behavior during the conscious sedation of pediatric dental patients. Results revealed that the addition of oral meperidine to chloral hydrate and hydroxyzine pamoate resulted in improved behavior (P less than 0.01) during local anesthetic injection, rubber dam delivery, and the operative dental procedure. There was no increase in the prevalence of respiratory compromise with the addition of meperidine.

Time required for placement of composite versus amalgam restorations.

This study was designed to develop an indirect method for measuring the time required for restoration placement; and to compare the operator time required for placement of amalgam and composite resins in posterior teeth in children. Forty children, aged seven to nine years old, were selected to participate. Either amalgam or an experimental resin was used to restore the primary and permanent molars. All restorations and sealants were completed under the rubber dam. Each restorative appointment was videotaped with a color video camera mounted on the ceiling. Ninety-six restorative procedures were reviewed and evaluated for the amount of time necessary to accomplish them. The Class I permanent molar composite restoration required 35 percent more insertion and finishing time than did the amalgam.

An investigation of capnography and pulse oximetry as monitors of pediatric patients sedated for dental treatment.

Traditional methods of monitoring sedated pediatric dental patients have major shortcomings. This study evaluated the use of capnography in conjunction with pulse oximetry for monitoring children during conscious sedation for dental treatment. The specific purposes of the study were to determine if capnography would: (1) detect ventilatory changes that subsequently cause an oxyhemoglobin desaturation as detected by pulse oximetry; and (2) detect an airway obstruction. Ten pediatric dental patients (mean age 2 years, 10 months) were sedated with 75 mg/kg of chloral hydrate in strict accordance with the Guidelines for the Elective Use of Conscious Sedation, Deep Sedation, and General Anesthesia in Pediatric Patients of the American Academy of Pediatric Dentistry and the American Academy of Pediatrics (1985). All patients were monitored continuously using both capnography and pulse oximetry. Analysis of data obtained using these monitors revealed that specific end-tidal CO2 values were not predictive for subsequent oxyhemoglobin desaturations and that capnography was very accurate in detecting complete obstruction of the airway. Pulse oximetry revealed that all patients had mild oxyhemoglobin desaturations and that 50% had moderate desaturations.

Acquisition of psychomotor skills in tooth preparation using self-paced instruction.

Self-paced instruction whereby students are provided with learning resources and allowed to learn at their own rate--with or without assistance from instructors--is increasingly being used in dental education. The wide diversity of entering dental student experience with psychomotor tasks suggests that preclinical psychomotor skill development should adapt well to self-paced learning. This study compared self-paced instruction to traditional preclinical teaching of psychomotor skills in cavity preparation. Performance by the self-paced class was significantly better than that of the traditional class on two procedures. There were no significant differences among the other procedures tested.