State regulations governing oral sedation in dental practice.

PURPOSE: The purpose of this study was to survey 50 state dental boards concerning their regulations governing the practice of moderate sedation administered by the oral route. METHODS: An online search was conducted to review each state's dental practice act. When interpretation of the information provided online was difficult, clarification was achieved by contacting that state board directly by telephone interview. To assist in further interpretation, the ADA's Statutory Guidelines for Conscious Sedation Permit were reviewed for comparison with the data collected. RESULTS: Forty-one states required a permit to administer moderate sedation by the oral route. Every state except Kansas required minimum didactic educational requirements for permit issuance. Every state required monitoring of the patient throughout the procedure and during recovery until discharge. In addition, all states expected the practitioner and clinical staff to be adequately trained to manage a sedation-related emergency. CONCLUSIONS: State dental boards have significantly increased regulation of oral sedation over the past 10 years, but vary widely in their permit requirements for issuance. This dis-harmony among the states should foster the national desire to develop a more unified approach in regulating oral sedation.

Impact of office-based intravenous deep sedation providers upon traditional sedation practices employed in pediatric dentistry.

PURPOSE: This survey intended to determine how the implementation of office-based IV deep sedation by a third party provider (OIVSED) impacted the traditional sedation practices employed in pediatric dentistry private practice settings. METHODS: A digital survey was e-mailed to 924 members of the American Academy of Pediatric Dentistry practicing in California, Florida, and New York, chosen because these states had large samples of practicing pediatric dentists in geographically disparate locations. RESULTS: 151 pediatric dentists using OIVSED responded to the survey. Improved efficiency, safety and quality of care provided, and increased parental acceptance were reported advantages of this service. Although less costly than hospital-based general anesthesia, the average fee for this service was a deterrent to some parents considering this option. Sixty-four percent of respondents continued to provide traditional sedation modalities, mostly oral sedation, in their offices, as parenteral routes taught in their training programs were less often selected. CONCLUSIONS: OIVSED users reported both a reduction in the use of traditional sedation modalities in their offices and use of hospital-based GA services in exchange for perceived improvements in efficiency, safety and quality of care delivered. Patient costs, in the absence of available health insurance coverage, inhibited accessing this service by some parents.

Pulp therapy in primary teeth--profile of teaching in Brazilian dental schools.

This study investigates the profile of teaching primary tooth pulp therapy practiced by Brazilian dental schools. A multiple-choice questionnaire was sent by e-mail to 191 dental schools in Brazil, addressed to the pediatric dentistry Chairperson. The two-part survey consisting of multiple-choice questions regarding specific materials and techniques on pulp therapies, moreover, hypothetical clinical scenarios were presented so that the respondents could guide the treatment approach. The questionnaires were returned by 46.5% of the dental schools. Ninety-five percent of surveyed schools teach IPT for the treatment of deep carious lesions in dentin and indicate the calcium hydroxide as capping material (59.3%). The direct pulp capping is taught by 68.7% of schools and calcium hydroxide (97%) was the capping material most indicated. Pulpotomy is taught in 98.7% of schools and formocresol (1:5 dilution) was the medicament of choice (50%). All schools taught pulpectomy and Iodoform paste was the filling material preferred (55%). The results showed a lack of consensus in certain modalities and techniques for primary tooth pulp therapy taught by Brazilian dental schools.

Oral characteristics of children with attention-deficit hyperactivity disorder.

The purpose of this study was to compare the oral and demographic characteristics of children with attention-deficit hyperactivity disorder (ADHD) to those of a control group of children. A sample of 25 dental records of children medicated for ADHD was compared to 127 records of healthy children not receiving any medication. The children with ADHD had a statistically higher prevalence of toothache, bruxism, bleeding gums, and oral trauma histories than the control group (chi square, p < 0.05). The differences in other recorded oral characteristics and habits, such as plaque accumulation, gingival inflammation, calculus, oral hygiene compliance, dental caries experience, and unmet dental needs, were not statistically significant. The demographic characteristics such as age, gender, residence, ethnicity, income, and payment method were also not significantly different between the two groups. There is a need to develop and implement specific strategies for the early prevention and treatment of oral diseases in children with ADHD.

The relationship between oral and demographic characteristics of children with asthma.

The information from 291 children's dental charts was analyzed; 127 children had no mental or systemic diseases, 50 had asthma and 114 had other diseases. Children with systemic diseases in general and those with asthma had a higher prevalence of history of toothaches and higher plaque, calculus and caries indices than the healthy children. Children with systemic diseases in general and those with asthma in particular should be targeted for preventive dental services.

Radiographic assessment of primary molar pulpotomies restored with resin-based materials.

PURPOSE: The aims of this study were to: (1) retrospectively assess the overall performance of formocresol pulpotomies in primary molars when definitively restored with a resin-based material; and (2) compare the results to previously published studies using more traditional restorative techniques (stainless steel crown, amalgam). METHODS: Records of a 2-operator pediatric dental office using this novel restorative technique were reviewed. Pre- and postoperative radiographs of pulpotomized primary molars restored with Z-100 and with a minimum of 6 months of follow-up were compared to the contralateral nonpulpotomized tooth. Radiographic success was determined by the absence of furcation/periapical osseous radiolucency and internal/external pathologic root resorption. Patient's age, gender, tooth type and arch, follow-up time, ZOE base type used (IRM only or IRM with glass ionomer overlay), and number of surfaces involved were the variables analyzed in the study. Statistical analysis was performed using chi-square analysis. RESULTS: Fifty-nine teeth in 52 patients met the selection criteria. Patient's age at treatment ranged between 44 and 118 months, with an average follow-up time of 21 months (range = 7 to 43). Significant failure rate was found in the mandibular arch (P = .035). When only the occlusal surface was restored, 100% success was obtained. With proximal restorations, 83% (15/18) success was obtained when the base was IRM followed by glass ionomer and 69% (22/32) success for IRM only (P = .259). CONCLUSIONS: Overall, restoration of pulpotomized primary molars with resin-based material was inferior to reported success rates using stainless steel crowns. When proximal surfaces were restored, the failure rate (26%) was comparable to amalgam (23%). Prospective studies with larger sample size are necessary for definitive conclusions.

A retrospective assessment of zinc oxide-eugenol pulpectomies in vital maxillary primary incisors successfully restored with composite resin crowns.

PURPOSE: The purpose of this retrospective study was to evaluate, via clinical and radiographic assessments, the treatment outcome of zinc oxide-eugenol (ZOE) pulpectomies performed in vital maxillary primary incisors successfully restored with composite resin crowns. METHODS: Pulpectomized vital primary incisors were treated by a uniformed technique, filled with ZOE paste, and successfully restored with composite resin crowns. Those that remained intact and noncarious for the assessment interval were evaluated for the outcome (success or failure) based on clinical and radiographic findings and compared to: (1) the reason for treatment; (2) the canal filling extent; (3) the type of composite resin crown restoration performed; and (4) the eruption status of its succedaneous tooth. RESULTS: For 104 maxillary primary incisors meeting the inclusion criteria, failure, as judged by presence of pathologic root resorption and/or apical lucency, was determined to be 24% (25/104), for a mean duration of 18 months observation. Failures were statistically associated with the reason for treatment (higher for trauma), the extent of ZOE paste filler in the pulp canal (higher for gross overfill), and the eruption status of the associated succedaneous permanent incisor (higher for delayed eruption). CONCLUSIONS: This study determined a failure rate (24%) for pulpectomies-using ZOE paste and performed on vital primary incisors-comparable to that reported for nonvital pulpectomies. A statistically significant increase in failure rates was found for: (1) incisors treated for trauma (42%) vs those treated for dental caries (19%); and (2) grossly overfilled canals (80%) vs canals filled to the apex (0%).

Comparison of drops versus spray administration of intranasal midazolam in two- and three-year-old children for dental sedation.

PURPOSE: The purpose of this retrospective record review of 2- and 3-year-old dental patients receiving intranasal midazolam (INM) was to compare drops vs spray administration to behavioral outcomes observed for agent acceptance during administration and for agent efficacy during parental separation, local anesthesia injection, and delivery of restorative dentistry. METHODS: Temperament and attachment scores based on adaptability and approachability determinants judged by the parent and interactive and Frankl behavior rating scores determined by the operator were used to compare preoperative behavioral characteristics between the 2 groups. The Ohio State Behavioral Rating Scale (OSBRS) and the Frankl behavior rating scale were used to determine intraoperative behavioral outcomes for agent acceptance and efficacy. RESULTS: Analysis of 64 sedation records revealed that the 2 groups had similar preoperative behavioral characteristics. Improvements in the Frankl behavioral rating scores were observed during the sedation, but no statistically significant difference between the drops and spray groups was measured using the OSBRS. For the procedural event of drug administration, however, the spray group demonstrated a statistically significant reduction (P=.025) in aversive behaviors when compared to drops administration as measured by the OSBRS. This finding was observed, even though the volume of spray was greater than used in the drops group. CONCLUSIONS: Spray administration of INM produced significantly less aversive behavior than administering drops in 2- to 3-year-old dental patients of similar behavioral characteristics. The effectiveness of the conscious sedation technique was not influenced by the method of nasal administration. This study suggested that the use of a commercially available atomizer improved patient acceptance of INM administration but did not influence agent efficacy compared to drops administration for 2- to 3-year-old dental patients in an office setting.

Aggressive periodontitis of the primary dentition associated with idiopathic immune deficiency: case report and treatment considerations.

The present case, of a child with an idiopathic immune deficiency and aggressive periodontitis in the primary dentition, serves as an example for the treatment considerations in these cases. Extraction of all the primary teeth proved to be the most adequate treatment. It allowed the child to eat properly and prevented unwanted infections that could endanger the life of the child. The newly erupted permanent teeth have been subjected to careful oral hygiene, clorhexidine topical applications, and have mild gingival inflammation and no attachment loss.

Allergic reaction to intranasal midazolam HCl: a case report.

An acute allergic reaction in a 5-year-old healthy male, after receiving midazolam by intranasal atomizer for sedation purposes in the dental clinic, was reported. Shortly after the midazolam was provided, the child developed urticaria in both ankles, which rapidly progressed to the lower extremities, stomach, back, arms, neck, and face. The periorbital skin also became edematous. In the emergency room, the diagnosis of an urticaria allergic reaction was confirmed. The child was treated with intramuscular diphenylhydramine, discharged from the emergency room after 5 hours, and prescribed oral diphenylhydramine (Benadryl) and prednisolone (Orapred). Children who receive sedatives such as midazolam in the dental clinic should be carefully monitored from the moment they receive the sedative, in order to disclose and treat undesirable side effects of the sedative agents as early as possible. The implications of allergic reactions to sedative agents in the dental clinic are reviewed.

Influence of site preparation methods on the pain reported during palatal infiltration using the Wand Local Anesthetic System.

PURPOSE: To compare different site preparation methods and their effect on the pain reported during local anesthetic infiltration at the palatal site. The study compared the following tissue site preparation methods: application of a topical anesthetic agent, pressure anesthesia achieved with a cotton tip applicator, a combination of both methods, and neither method (non-placebo control). MATERIALS AND METHODS: 15 adult subjects received a total of four palatal injections, one with each type of site preparation in a randomized order over two appointments (two injections per appointment). Bilateral palatal injections were performed in a standardized manner using the uniform slow flow rate produced by the Wand Local Anesthetic System through a 30-gauge needle. Pain response was measured by subject self-report using the visual analogue scale (VAS), a quantified verbal descriptor scale (Gracely), and a comparison to prior injection experience, as well as the operator's global assessment of the subject's pain response. RESULTS: All recorded pain measurements failed to demonstrate statistical differences for the various site preparations tested. The scores for the VAS and the Gracely scales were statistically in agreement. When administering a slow flow rate of anesthetic solution at the palatal site, this study demonstrated that the intensity of pain reported by adult subjects was minimal. The low intensity of reported pain, measured in several different ways, failed to discriminate among the various site preparation methods tested.

Influence of anesthetic flow rate delivered by the Wand Local Anesthetic System on pain response to palatal injections.

PURPOSE: To compare pain response between two different flow rates (slow versus fast) of local anesthetic solution injected into palatal tissue using the recently available Wand Local Anesthetic System (WLAS), which provides the technologic advance to permit reliable replication of constant injection flow rates, regardless of tissue resistance. METHODS AND MATERIALS: Twenty adult subjects received bilateral palatal injections of local anesthetic in random sequence during the same appointment following topical anesthesia application. Pain response was measured by subjective self-report using a visual analogue scale, a quantified verbal descriptor scale, and a comparison to prior injection experience, as well as an operator's global assessment of the subject's pain response. Heart rate, as a physiologic indicator of pain response, was also recorded. RESULTS: All measurements of pain response were statistically less for the slow compared to the fast injection rate. No significant difference in mean heart rate, however, was demonstrated between the two flow rates. A slow, constant flow rate (161 sec/mL) of a 0.3 mL volume of local anesthetic solution was statistically less painful than a fast flow rate (29 sec/mL) during palatal injection. Contrary to the manufacturer's claim, the WLAS reduced but did not eliminate pain elicited by palatal injections in some patients.

Changes in incremental weight and well-being of children with rampant caries following complete dental rehabilitation.

PURPOSE: The purposes of this study were to determine if young children with rampant dental caries that received complete dental rehabilitation under general anesthesia: 1.) weighed less preoperatively compared to national norms; and 2.) demonstrated significant improvement postoperatively in percentile weight gain and/or quality of life indicators. METHODS: The preoperative and postoperative percentile weights based on national norms were calculated for children, aged 2-7 years old, with non-significant medical histories (absence of systemic illness) that underwent rehabilitation for rampant dental caries under general anesthesia. Changes in the quality of the children's life following dental rehabilitation under general anesthesia were determined from parental report. RESULTS: The results showed that there was a slight, non-significant increase in the mean percentile weight following dental rehabilitation under general anesthesia. There was no significant effect on the mean net percentile weight change based on the chronological age or weighing interval. There was, however, a significant improvement in the children's quality of life as reported by their parents. CONCLUSIONS: Contrary to previous reports, the mean percentile weight of children with rampant dental caries was not below the 50th percentile and the slight gain in percentile weight following dental rehabilitation under general anesthesia was not indicative of a "catch-up growth" phenomenon. There was, however, a significant improvement in the children's quality of life as based upon parental report and confirmed in a previous investigations.

Microleakage and wall adaptation of conservative restorations.

PURPOSE: To evaluate the microleakage and wall adaptation of different restorative materials in sealed and unsealed conservative restorations after storage in an acid environment. MATERIALS AND METHODS: 100 conservative cavity preparations were prepared in the occlusal surface of 50 non-carious, extracted human permanent molar teeth. The teeth were divided into 5 groups and restored with either flowable compomer, compomer, amalgam, resin-based composite or non-bonded resin-based composite (control). One half of the restorations in each group was sealed with a light cured unfilled sealant material, while the other half was left unsealed. The teeth were placed in artificial saliva for 30 days, radiographed, thermocycled 500 times, placed in an artificial caries solution, immersed in dye, sectioned three times, and recorded at x60 magnification. Three independent examiners assessed each of the 300 recorded sections for leakage and assessed each radiograph for wall adaptation using a slide projector. Kruskal Wallis and Mann-Whitney nonparametric tests were used to analyze the results. RESULTS: Sealed restorations showed significantly less leakage than unsealed (P < 0.001). Of the sealed groups, amalgam showed less leakage than flowable compomer (P = 0.027). Of the unsealed groups, flowable compomer showed less leakage than both composite groups (P = 0.032 and P = 0.045). Radiographically, the two compomer groups and the amalgam group had fewer adaptation voids than both composite groups (P < 0.001).