Pediatric Sedation in Dutch Dental Clinics: The Influence of Guideline Modifications on Adverse Events.

Background: Dental fear and uncooperative behavior can hinder dental treatment quality. Pediatric Procedural Sedation and Analgesia (PPSA) is used to facilitate treatment when the coping capacity is exceeded. Out-of-hospital PPSA has been associated with more adverse outcomes compared to when it is used in hospital-based settings. The updated Dutch PPSA guidelines have increased costs and raised concerns about the accessibility of specialized high-quality dental care for children in the Netherlands. This study aimed to investigate the impact of the updated 2017 guidelines on the occurrence rate of adverse events during PPSA in twelve Dutch dental clinics. Methods: The data of 25,872 children who were treated at twelve dental clinics between 1997 and 2019 were analyzed. A logistic two-level mixed-effects model was used to estimate the updated guidelines' impacts on adverse events. Results: The OR of the occurrence rate of an adverse event adjusted for age, weight, and duration of treatment was 0.75 (95% CI 0.64-0.89) after the implementation of the updated guidelines. This outcome was significant with p = 0.001, indicating a protective effect. Conclusions: Our findings demonstrate that there was a significant reduction in adverse events after the implementation of the updated guideline and highlight the importance of adhering to evidence-based practices in out-of-hospital dental clinics.

Relationship between Child and Parental Dental Anxiety with Child's Psychological Functioning and Behavior during the Administration of Local Anesthesia.

OBJECTIVES: The aims of this study were to determine: 1) the relationship between children's psychological functioning, dental anxiety and cooperative behavior before and during local anesthesia, 2) the relationship of parental dental anxiety with all the above child characteristics. STUDY DESIGN: There was a convenient sample of 100 children (4-12 years). Child dental anxiety and psychological functioning were measured using the "Children's Fear Survey Schedule" (CFSS-DS) and the "Strengths and Difficulties Questionnaire" (SDQ) respectively. Parental dental anxiety was measured using the "Modified Dental Anxiety Scale" (MDAS). All questionnaires were completed by parents. Before and during local anesthesia, the child behavior was scored by one experienced examiner, using the Venham scale. Non-parametric tests and correlations (Mann-Whitney, Spearman's rho) were used for the analysis. RESULTS: The mean SDQ score was 10±5.6 for boys (n=60) and 8.3±4.8 for girls (n=40) (p=0.038), but there was no correlation with children's age. The mean CFSS-DS score was 33.1±11.86 and there was no correlation with age or gender. Children with higher levels in the pro-social subscale of the SDQ had significantly less anxiety and better behavior before local anesthesia. Higher mean CFSS-DS scores were significantly associated with uncooperative behavior during local anesthesia (p=0.04). There was no correlation between parents' and their children's dental anxiety, psychological functioning and behavior. 46% of the children had previous dental experience in the last 6 months. As time since the last dental treatment increased, an improvement was found in children's behavior during local anesthesia. CONCLUSIONS: Child psychological functioning was related to dental anxiety and behavior during dental appointment involving local anesthesia.

Ethnic Disparities in Dental Caries among Six-Year-Old Children in the Netherlands.

The aim of this study was to investigate potential differences in caries prevalence of children from ethnic minority groups compared to native Dutch children and the influence of socio-economic status (SES) and parent-reported oral health behaviour on this association. The study had a cross-sectional design, embedded in a population-based prospective multi-ethnic cohort study. 4,306 children with information on caries experience, belonging to 7 different ethnic groups, participated in this study. The decayed, missing, and filled teeth (dmft) index was assessed at the age of 6 and categorized in two ways for analysis: children without caries (dmft = 0) versus any caries experience (dmft >0) and children without caries (dmft = 0) versus children with mild caries (dmft = 1-3) or severe caries (dmft >3). Compared to native Dutch children, children with a Surinamese-Hindustani, Surinamese-Creole, Turkish, Moroccan, and Cape Verdean background had significantly higher odds for dental caries. Especially the Surinamese-Hindustani, Turkish, and Moroccan group had significantly higher odds for severe dental caries. Household income and educational level of the mother explained up to 43% of the association between ethnicity and dental caries, whereas parent-reported oral health behaviour did not mediate the association. Alarming disparities in caries prevalence between different ethnic (minority) groups exist, which cannot be fully explained by social inequalities. Public health strategies can apply this new knowledge and specifically focus on the reduction of ethnic disparities in oral health. More research is needed to explain the high caries prevalence among different ethnic minority groups.

Longitudinal Changes in Dental Fear and Coping Behavior in Children, Adolescents, and Young Adults With Cleft Lip and/or Cleft Palate.

OBJECTIVE: To determine changes in dental anxiety levels of cleft lip and/or palate (CL/P) children and to explore the role of coping strategies in the development of their dental anxiety. DESIGN: Prospective study. SETTING: Free University Medical Center Amsterdam. PATIENTS: A sample of CL/P children (at T1: n = 153, 4 to 18 years, 67 girls; at T2: n = 113, 7 to 21 years, 51 girls). Data were available at both time points for 102 children. MEASURES: Dental anxiety and coping strategies were assessed at the start of the study (T1; mean age: 9.8 years, standard deviation 4.1) and 3 years later (T2; mean age: 13.4 years, standard deviation 3.8). These scores were compared to a normative group of Dutch children. MAIN OUTCOME MEASURE(S): The severity of dental anxiety was indexed using the Parental Version of the Dental Subscale of the Children's Fear Survey Schedule. Dental coping strategies were assessed with the Dental Cope Questionnaire. RESULTS: Overall, dental anxiety decreased to a level equal to normative scores of Dutch children. However, 5% of the children became more anxious. At T2, children used significantly fewer coping strategies. Children whose level of dental anxiety increased significantly used more destructive coping strategies than children whose level of dental anxiety decreased significantly or remained stable. CONCLUSIONS: Results suggest that dental anxiety levels of most CL/P children gradually decline over time. Whereas some coping strategies have the potential to be protective, more destructive coping strategies may put children at greater risk for developing and maintaining their dental anxiety.

Pre- and postnatal determinants of deciduous molar hypomineralisation in 6-year-old children. The generation R study.

BACKGROUND: Deciduous Molar Hypomineralisation (DMH) and Molar Incisor Hypomineralisation (MIH) are common developmental disturbances in pediatric dentistry. Their occurrence is related. The same determinants as suggested for MIH are expected for DMH, though somewhat earlier in life. Perinatal medical problems may influence the prevalence of DMH but this has not been studied sufficiently. OBJECTIVE: This study aimed to identify possible determinants of DMH in a prospective cohort study among 6-year-old children. STUDY DESIGN: This study was embedded in the Generation R Study, a population-based prospective cohort study from fetal life until young adulthood. The the data were used to identify the determinants of DMH. Clinical photographs of clean, moist teeth were taken with an intra-oral camera in 6690 children (mean age 6.2 years; 49.9% girls). Data on possible determinants that had occurred during pregnancy and/or the child's first year of life were on the basis of manual standardized measurements (like length and weight) and questionnaires. Multivariate analyse with backward and forward selection was performed. RESULTS: A number of factors in the pre-, peri- and postnatal phase were found to be associated with DMH. After multivariate logistic regression analyses, Dutch ethnic background, low birth weight, maternal alcohol consumption during pregnancy, and fever episodes in the first year of the child's life were found to play a role in the development of DMH in 6-year-old children. CONCLUSION: This study shows that Dutch ethnicity, low birth weight, alcohol consumption by the mother during pregnancy and any fever in the first year of the child's life are associated with DMH. Not only childhood factors but also prenatal lifestyle factors need to be taken into account when studying determinants for DMH.

Is maternal use of medicines during pregnancy associated with deciduous molar hypomineralisation in the offspring? A prospective, population-based study.

BACKGROUND: The effects of maternal use of medicines during pregnancy on tooth development has scarcely been studied; only negative effects of tetracycline on tooth germs are known (irreversible tooth discoloration and enamel hypoplasia). OBJECTIVE: The aim of this study was to investigate whether antibacterials and anti-allergic and anti-asthma medicines, being the most frequently used medicines during pregnancy, are associated with deciduous molar hypomineralisation (DMH) and, if so, which specific medicines. MATERIALS AND METHODS: To clarify this possible association, the participants of the Generation R Study, a population-based prospective cohort study from fetal life until young adulthood, were studied. Data on medicine use during pregnancy were retrieved from pharmacies. Clinical photographs of the second primary molars, which were scored for DMH, were taken with an intra-oral camera in 6,690 children (mean age 6.2 years, standard deviation [SD] ± 0.53; 49.9 % girls). RESULTS: During pregnancy, 20.3 % of the mothers used antibacterials, 12.3 % anti-asthma medicines and 5.4 % anti-allergic medicines. The prevalence of DMH was 9.0 % in the study group. There was no association between the use of anti-asthma medicines, anti-allergic medicines (odds ratio [OR]: 0.97 [95 % CI 0.61-1.54]; OR: 1.04 [0.54-2.03]) or antibacterials (OR: 0.73 [0.49-1.09]) during pregnancy and DMH (all p-values >0.05). The study had sufficient power (80 %) to detect significant associations. CONCLUSION: Maternal use of antibacterials, anti-allergic medicines or anti-asthma medicines during pregnancy is not associated with the development of DMH in the offspring.

Measuring dental fear using the CFSS-DS. Do children and parents agree?

BACKGROUND: In most studies, the parental version of the CFSS-DS is used; however, no information is available concerning the extent to which parents are able to report dental fear on behalf of their children. AIM: This study aims to assess whether parents are accurate reporters of their child's dental fear. METHODS: The CFSS-DS was filled out by 326 children in a classroom setting and by 167 parents (mostly mothers) at home on behalf of their child. Intraclass correlation coefficients were used as a measure of agreement between both CFSS-DS versions, and reasons for nonagreement were assessed. RESULTS: Mean CFSS-DS for children was 21.15 (SD = 6.4) and for parents 23.26 (SD = 6.7). The intraclass correlation coefficient was 0.57. After selection of the 73.1% most accurate reporting parents, the ICC was 0.90. In general, parents estimate the dental fear of their children higher than their children do (P ≤ 0.001), whereas parents of high anxious children (HAC) estimate this fear lower, and parents of low anxious children (LAC) estimate this fear higher. Anxious parents (AP) estimate the dental fear of their children significantly higher than nonanxious parents (NAP) (P ≤ 0.001), but the children of AP do not estimate their own dental fear higher than children of NAP. CONCLUSIONS: In general, parents tend to estimate the dental fear of their children slightly higher than their children.

Frameshift mutations in dentin phosphoprotein and dependence of dentin disease phenotype on mutation location.

We describe results from a mutational analysis of the region of the dentin sialophosphoprotein (DSPP) gene encoding dentin phosphoprotein (DPP) in 12 families with dominantly inherited dentin diseases. In eight families (five mutations in the N-terminal third of DPP), the clinical and radiologic features were uniform and compatible with dentin dysplasia type II (DD-II) with major clinical signs in the deciduous dentition. In the other families (four mutations in the more C-terminal part), the permanent teeth also were affected, and the diseases could be classified as variants of dentinogenesis imperfecta. Attrition was not prominent, but periapical infections were common. Discoloring with varying intensity was evident, and pulps and root canals were obliterated in the permanent dentition. All mutations caused a frameshift that replaced the Ser-Ser-Asx repeat by a code for a hydrophobic downstream sequence of approximately original length. We conclude that frameshift mutations in DSPP explain a significant part of dentin diseases. Furthermore, we propose that the location of the mutation is reflected in the phenotypic features as a gradient from DD-II to more severe disease that does not conform to the classic definitions of DI-II.

Factors increasing the caries risk of second primary molars in 5-year-old Dutch children.

BACKGROUND: Caries is still a prevalent condition in 5-year-old children. At present, knowledge regarding some aetiological factors, like deciduous molar hypomineralization (DMH), is limited. AIM: To investigate aetiological factors both directly and indirectly associated with caries in second primary molars. DESIGN: Of 974 children invited to participate in the study, 386 children were examined clinically with visual detection of caries. Only carious lesions determined to have reached the dentine were recorded. Information about tooth brushing frequency, education level of the mother, and country of birth of mother and child, was collected by means of a multiple-choice questionnaire. Parents of 452 children filled in the questionnaire. Complete clinical and questionnaire data were available for 242 children. Statistical analysis of the effect of the independent variables was undertaken using the Pearson's chi-squared test. RESULTS: Deciduous molar hypomineralization (P = 0.02) and the country of birth of the mother (P < 0.001) were positively associated with caries prevalence. CONCLUSIONS: Deciduous molar hypomineralization and the country of birth of the mother play a role in the prevalence of dental caries. These aetiological factors associated with childhood dental caries need to be investigated further in longitudinal clinical trials.

Dental Discomfort Questionnaire: its use with children with a learning disability.

This study investigated whether the behaviors from the Dental Discomfort Questionnaire (DDQ) could help identify toothaches in children with a learning disability, who have a limited capacity to self-report. The objectives were to examine whether the behaviors from the DDQ occur more often in children with a learning disability who have caries and a toothache than in children who do not have caries and a toothache; and secondly, to examine whether two additional items increase the specificity and sensitivity of the DDQ to recognize a toothache, in this particular population of children with a learning disability. The DDQ was completed by a convenience sample of 58 parents on behalf of their children: 31% girls, aged between 6 and 13 years (mean = 7.5, SD = 2.7). Of the total group, 26% (n = 15) suffered from a toothache and 43% (n = 25) had carious teeth. Children with caries and a toothache had a significantly higher mean DDQ score and displayed more toothache-related behaviors (e.g., problems with chewing, problems with brushing teeth) than children without caries or toothache. The DDQ seems to be a functional and easy-to-use instrument to alert parents to the presence of a toothache in this specific group of children with a learning disability.

Children's self-reported pain at the dentist.

The aim of the present study is to get an insight into the pain report of children over two sequential dental visits. Furthermore, it was studied whether age, previous dental experience, level of dental anxiety and injection site were of influence on the self-reported pain of children during the first and second treatment session. One hundred and forty-seven children (4-11 years old) were included in the study. After receiving a local anesthesia injection prior to their dental treatment, they were asked how much pain they had felt. The level of dental anxiety was measured once by the parental version of the Dental Subscale of the Children's Fear Survey Schedule. Young children with a low level of dental anxiety show a sensitized reaction trend for self-reported pain over two sequential dental visits. Young children with a high level of dental anxiety reported the most pain on the first treatment session. For the older children, the children having previous dental experience gave the highest pain ratings on the first treatment session. Furthermore, for both young and older children the amount of pain reported for the second injection was best predicted by the amount of pain reported for the first injection, whereby higher scores the first time predict higher scores the second time. In conclusion, the memory of previous experience with dentistry and earlier treatment sessions seems of great influence on the behaviour and the experience of children during subsequent treatment sessions.

Dental anxiety in relation to emotional and behavioral problems in Croatian adolescents.

The investigation was performed on 113 adolescents in the age between 15 and 18 years (63 boys, 50 girls). Corah Dental Anxiety Scale (CDAS) and Children's Fear Survey Schedule - Dental Subscale (CFSS-DS) were used for evaluation of dental fear and Child Medical Fear Questionnaire (CMFQ) for evaluation of the fear of medical treatment. Achenbach Youth Self Report questionnaire (YSR) was used for evaluation of emotional and behavioral problems. The tests were filled in by children. The aim of the study was to evaluate the level of dental anxiety in adolescents and to assess a cause--consequence relationship between dental anxiety and emotional and behavioral problems in adolescents. The results of CDAS, CFSS-DS and CMFQ tests showed that dental anxiety scores and the total internalizing problems were higher in girls. Girls displayed more physical problems (p < 0.001) and were more prone to anxiety/depression disorders (p < 0.05). Both boys and girls were more aggressive, more prone to delinquent behaviour and had more externalizing problems in comparison with the average values obtained for the Croatian population. Significant correlation coefficients for boys were calculated for age and anxiety/depression, and delinquent behaviour and aggression (p < 0.05). Significant correlations were observed between physical problems and dental anxiety measured by the CFSS-DS test (p < 0.01), and between physical problems and the total internalizing problems (p < 0.05). In girls, the CMFQ scores showed significant correlations between dental anxiety and physical problems (p < 0.05), and anxiety/ depression (p < 0.01) and the total internalizing and externalizing problems (p < 0.05). Significant correlations were calculated for age and the total internalizing and externalizing problems for boys (p < 0.05). According to the results of both CDAS and CMFQ tests, anxiety in girls showed significant correlations with delinquent behaviour (p < 0.01). CDAS scores for girls showed significant correlations with aggression (p < 0.05) and the total externalizing problems (p < 0.01).

Dental Discomfort Questionnaire: assessment of dental discomfort and/or pain in very young children.

OBJECTIVE: To present and analyse the Dental Discomfort Questionnaire (DDQ) for very young children and to assess the possible differences in pain-related behaviours displayed by children with or without reported toothache, and by children with or without decayed teeth. METHODS: Based on parental interviews of toddlers referred to a dental care practice 12 pain-related behaviours were identified which formed the DDQ. The DDQ was filled out by parents on behalf of their children (n = 146; mean age 47 months). Two-third (n = 94) of the children were referred to a special dental care centre and one-third (n = 52) were controls from a day care centre. RESULTS: The results show that the 12 items of the DDQ seem to measure one dimension. However, four items do not correlate with the presence of reported toothache, when these items are removed the DDQ-8 has a satisfactory reliability. All eight behaviours from the DDQ-8 occur significantly more often in children with decayed teeth and toothache than in children without decayed teeth or toothache. Especially behaviours concerning eating or brushing teeth are found to be more often present in children with decayed teeth and toothache. CONCLUSIONS: It seems useful to take the child behaviour into account in assessing toothache. The DDQ has shown to be a reliable instrument, which could be helpful in the future for both parents and dentists in identifying toothache in young children.

Computerized anesthesia delivery system vs. traditional syringe: comparing pain and pain-related behavior in children.

The aim of this study was to compare the behavioral reaction of children who receive local anesthesia with a traditional syringe with the behavioral reaction of children who receive local anesthesia with a computerized device (Wand) and to differentiate between the reactions of highly anxious children with those displaying low anxiety. One hundred and twenty-five children aged 4-11 yr were randomly allocated to receive local anesthesia with the Wand or a traditional injection. Parents completed the Dental Subscale of the Children's Fear Survey Schedule (CFSS-DS). Two independent observers scored videotapes of the anesthesia in 15-s intervals. The occurrence of muscle tension, crying, verbal protest, movement, and resistance was registered and a score was given on the Venham distress scale. The mean injection time with the Wand was four times as long as with the traditional syringe. During the first 15 s of the injection, low-anxious children receiving local anesthesia with the Wand displayed less muscle tension, less verbal protest and less movement than children receiving local anesthesia with the traditional syringe. Within the high-anxious group no differences were found. It was concluded that low-anxious children seem to benefit from the use of the Wand instead of the traditional syringe in receiving local anesthesia.

Dental discomfort questionnaire for young children before and after treatment.

OBJECTIVE: To present a follow-up using the Dental Discomfort Questionnaire (DDQ) before and after the treatment of children, under the assumption that the number of toothache-related behaviors diminishes as a result of treatment, and to see whether this effect is related to the site of the carious teeth or to the treatment itself. METHODOLOGY: Sixty-one parents completed the DDQ before and after the treatment of their child, aged between 30 and 59 months. The available dental records were used to assess the status of the caries and the consecutive treatment. RESULTS: Overall, there was a significant decrease in the average number of post-treatment behaviors displayed by children. However, children with extractions during treatment or children with caries in their front teeth did not change their behavior. These children continued to have difficulty with chewing and biting. CONCLUSIONS: The dental treatment of children leads to reduced toothache-related behaviors. Our study showed the DDQ to be a useful instrument for acquiring insight into the behavioral aspects of young children as a consequence of toothache or dental treatment, thereby underlining the importance of a behavioral approach in young children.

Children's coping with pain during dental care.

OBJECTIVES: The purpose of this study was (i) to assess the coping strategies of 11-year-old children when dealing with pain at the dentist, (ii) to determine the extent to which the level of the children's dental fear and their experience with pain at the dentist are related to their ability to cope and their choice of strategies, and (iii) to analyse the possible differences between subsamples concerning dental caries. METHODS: The coping strategies were investigated using the Dental Cope Questionnaire (n = 597); the level of dental fear was assessed using the Children's Fear Survey Schedule (CFSS-DS); a question is asked whether a child had experienced pain at the dentist in the past and dental caries was assessed using the DMFS index. RESULTS: The results show that 11-year olds use a variety of coping strategies. Internal strategies are used most frequently, external coping strategies are used less frequently, and destructive strategies are hardly used. The subjects rate internal and external strategies as effective. Children with pain experience and fearful children use more coping strategies, with fearful children using more internal strategies. Reported pain and anxiety were related to the dental status. CONCLUSIONS: The use and choice of coping strategies seems to be at least partly determined by the level of dental fear and the child's experience with pain.

Assessment of pain by the child, dentist, and independent observers.

PURPOSE: The objective of this study was to analyze the assessment of pain and distress by the child, dentist, and independent observers during a dental injection and study the relationship between the different assessments. METHODS: The amount of pain experienced by the child during local anesthesia was reported independently by the child to both the dentist and parent on a 4-point scale running from "no pain" to "a lot of pain." The dentist and observers also gave a score for the pain experienced on a 4-point scale. The amount of distress experienced by the child during local anesthesia was assessed by the dentist and observers using a 6-point scale (from "relaxed" to "out of contact"). RESULTS: The dentists' pain assessment was the lowest. A substantial correlation was found between the child's self-reported pain and the pain as assessed by independent observers. There was a moderate correlation between the amount of distress and pain intensity as reported by the child during the anesthesia phase. CONCLUSIONS: Observation of a child in a videotaped procedure is apparently the most reliable method to accurately assess pain behavior and to discriminate pain from distress. A combination of the child's report and video observation is advised to assess pain in young children.

Relationship between needle phobia and dental anxiety.

PURPOSE: This cross-sectional study aimed to explain the nature of needle phobia and its relationship in dental phobic children with evidence on age-related differences. METHODS: The study used 2,865 patients (52% boys, 48% girls), 4 to 11 years old (mean=7.18 years). The patient sample included randomly selected patients (N=2,153) and an anxious group of children (N=712). Children were divided into 3 age groups (4-6, 7-9, and 10-11 years). The Children Fear Survey Schedule--Dental Subscale (CFSS-DS) was used to assess age-related needle phobia (CFSS-DS question 3) and dental anxiety. Children were arranged into 3 anxiety groups (cutoffs=scores of 25 and 37). Children who scored >37 were considered needle-phobic. Statistical analysis was performed using Statistics for Windows 10. RESULTS: Needle phobia progressively decreases with increasing age (19% of 4- to 6-year-old vs 11% of 10- to 11-year-old needle phobics; P< or =05). Stepwise regression analysis revealed needle phobia does not primarily seem to be related to dental anxiety. Other aspects, like having had someone examine the mouth and the dentist drilling, contribute the most to dental anxiety in both low- and high-anxiety children. Fear of doctors is more specific for high-anxiety children (P < or =05). A significant age-related difference regarding needle phobia is found between children ages 4 to 6 and 7 to 9 and between children ages 4 to 6 and 10 to 11 (P < or =001). CONCLUSIONS: Needle phobia is age related, but should be considered a separate phenomenon. It is not specific for dental anxiety and is related to other painful treatment.

Childhood dental fear in the Netherlands: prevalence and normative data.

OBJECTIVE: This study aimed to present normative data on dental fear for the Dutch child population, by identifying not only highly fearful children but also children at risk for developing this high dental fear. METHODS: Fear distribution of samples of high and low fearful children was studied, using the Dutch parent's version of the Dental Subscale of the Children's Fear Survey Schedule (CFSS-DS). Total fear scores were calculated for both samples, for different age levels and for boys and girls separately. To establish cut-off scores, mean CFSS-DS scores were associated with dentists' clinical fear ratings and, in addition, were transformed into stanines. RESULTS: Scores between 32 and 38 were found to represent a borderline area for dental fear, and scores of 39 and higher to represent high dental fear. CONCLUSION: The results have shown 6% of the Dutch child population to be highly fearful, while another 8% may be at risk to develop high dental fear. By providing extra attention for these children, the development of high dental fear or phobia may be prevented.