Intranasal Fentanyl Combined with Oral Midazolam for Pediatric Dental Sedation: A Controlled Randomized Blinded Crossover Clinical Trial.

Purpose: The purpose of this study was to compare the effectiveness of intranasal fentanyl combined with oral midazolam to oral midazolam alone in pediatric dental patients. Methods: Thirty-two uncooperative healthy children aged three to six years old, who met the inclusion criteria, were randomly assigned to receive oral midazolam (0.7 mg/kg) with either intranasal fentanyl (one µg/kg) or intranasal placebo (saline). A controlled, randomized, double-blinded, crossover clinical trial design was followed so that each child received both regimens. Data collected included the onset of sedation, working time, sedation and behavior assessment, and occurrence of side effects. Results: The onset of sedation time was not statistically different between the two groups (P=0.62), while the median working time of the midazolam/fentanyl sedation was sig- nificantly longer than the midazolam sedation (P<0.001). Sedation scores were significantly better with the midazolam/fentanyl sedation regimen at separation from parents (P=0.032), local anesthesia administration (P=0.018), rubber dam application (P=0.035), after five minutes of dental treatment (P=0.035), after 10 minutes (P=0.039), after 15 minutes (P=0.012), and after 20 minutes (P=0.038). Behavior scores were significantly better with the midazolam/fentanyl sedation only at local anesthesia administration (P=0.021), rubber dam placement (P=0.004), and after five minutes of dental treatment (P=0.049). Minor side effects occurred in 12.5 percent of sedation procedures and were not significantly associated with either of the two groups (P=0.70). Conclusion: The combination of oral midazolam with intranasal fentanyl sedation, when compared to oral midazolamas a single agent, significantly improved sedation and behavior during local anesthesia and operative dentistry for healthy three- to six-year-old children in addition to prolonged sedation working time.

Post-Discharge Effects and Parents' Opinions of Intranasal Fentanyl with Oral Midazolam Sedation in Pediatric Dental Patients: A Cross-Sectional Study.

The aim of this study was to evaluate the post-discharge effects of oral midazolam with intranasal fentanyl sedation in pediatric patients who had dental treatment and to evaluate parents' preference regarding sedation visits. METHODS: A total of 32 uncooperative healthy pediatric patients aged 3-6 years old who met the inclusion criteria were included. In the first visit, one group received oral midazolam (0.7 mg/kg) with intranasal fentanyl (1 µg/kg) sedation (M/F) and the other group received oral midazolam with intranasal placebo (M), and in the second visit each group received the other type of sedation in a cross-over type. In this cross-sectional study, a post-discharge phone-call questionnaire was carried out 24 h after both sedation visits with the parents to evaluate the children's behavior, function, balance, eating pattern, sleeping pattern, vomiting incidents, and any possible side effects, as well as parents' satisfaction and preference. The Wilcoxon signed-rank test was used to analyze the categorical variables, and the Chi-square test was performed to analyze the parents' preference. RESULT: A total of 32 parents responded to the phone-call questionnaire after 64 sedation visits. All of them were mothers. There was no statistically significant difference between the two groups with respect to recovery to normal function and balance, behavior, incidents of fever, vomiting, sleep disturbance, oversleeping, and adverse behavioral changes (p > 0.05). Children required a significantly longer amount of time until the first meal after M/F sedation (p = 0.04). No significant difference was found between parents' preferences regarding the sedation visits (p > 0.05). CONCLUSION: Intranasal fentanyl added to oral midazolam sedation could have an effect on post-discharge adverse behavioral changes, prolonged sleeping, and prolonged recovery time. Children sedated with midazolam/fentanyl required a longer amount of time until the first meal. Vomiting and fever occurred similarly in both sedation regimens with a low incidence. There was no difference in parents' preferences regarding the two sedation regimens.

Saudi dental students' opinions on the qualities and attributes of an effective dental teacher.

OBJECTIVE: To evaluate Saudi dental students' opinions on the qualities and attributes of an effective dental teacher. METHODS: This cross-sectional study was conducted between March and May 2014 at the College of Dentistry, King Saud University. Self-administered questionnaires were distributed to all students enrolled in the 2013/2014 academic year. The questionnaire contained 43 items regarding students' opinions on the qualities and attributes of a good dental teacher. The attributes were grouped into two main categories: performance and personality. Mean and standard deviations were calculated for each item and then for the whole category. Performance and personality were compared between male and female students and between junior and senior students using Mann-Whitney U test. RESULTS: Four hundred and seventy-seven questionnaires were completed, representing a response rate of 79%. Performance attributes were significantly more important than personality attributes to Saudi dental students (P<0.001). Perceptions of performance and personality attributes did not differ between male and female students; however, junior students put more emphasis on personality attributes than senior students. CONCLUSION: Saudi dental students consider performance attributes more important than personality attributes for their successful learning. Teachers' educational skills are valued more than the attributes, which do not connect directly to students' learning process.

Intranasal sedatives in pediatric dentistry.

OBJECTIVES: To identify the intranasal (IN) sedatives used to achieve conscious sedation during dental procedures amongst children. METHODS: A literature review was conducted by identifying relevant studies through searches on Medline. Search included IN of midazolam, ketamine, sufentanil, dexmedetomidine, clonidine, haloperidol, and loranzepam. Studies included were conducted amongst individuals below 18 years, published in English, and were not restricted by year. Exclusion criteria were articles that did not focus on pediatric dentistry.  RESULTS: Twenty studies were included. The most commonly used sedatives were midazolam, followed by ketamine and sufentanil. Onset of action for IN midazolam was 5-15 minutes (min), however, IN ketamine was faster (mean 5.74 min), while both IN sufentanil (mean 20 min) and IN dexmedetomidine (mean 25 min) were slow in comparison. Midazolam was effective for modifying behavior in mild to moderately anxious children, however, for more invasive or prolonged procedures, stronger sedatives, such as IN ketamine, IN sufentanil were recommended. In addition, ketamine fared better in overall success rate (89%) when compared with IN midazolam (69%). Intranasal dexmedetomidine was only used as pre-medication amongst children. While its' onset of action is longer when compared with IN midazolam, it produced deeper sedation at the time of separation from the parent and at the time of anesthesia induction. CONCLUSION: Intranasal midazolam, ketamine, and sufentanil are effective and safe for conscious sedation, while intranasal midazolam, dexmedetomidine, and sufentanil have proven to be effective premedications.

Combined orthodontic and periodontic treatment in a child with Papillon Lefèvre syndrome.

A 9-year-old girl with Papillon-Lefèvre syndrome (PLS) was treated orthodontically 24 months after the start of mechanical and antibiotic therapy in adjunct with periodontal treatment every 6 weeks. After achieving stable periodontal conditions, orthodontic treatment was commenced to correct the teeth position, facial profile, and maxillary protraction. Following the combination therapy and a failure to detect Actinobacillus actinomycetemcomitans from any site in the oral cavity, orthodontic treatment with a fixed appliance was performed aside from creating space for eruption of permanent teeth. We found that combined periodontal and orthodontic treatment of PLS may be successful with a complex interdisciplinary regimen and close follow up. This is a 2-year follow-up case report of a girl with PLS. Orthodontic and periodontic therapy were offered using combined treatments of orthodontic and periodontal with the benefit of prosthodontic consultation, resulting in a treatment plan.

Children's Perception of Their Dentists.

OBJECTIVES: The aim of this study was to assess school children's feelings and attitudes toward their dentist. METHODS: A questionnaire designed to evaluate children's attitudes and preferences toward dentists was completed by 583 children (289 females, 294 males) with age range 9-12 years attending public schools. RESULTS: 76% of the children who completed the questionnaire reported that they had been to the dentist before. Of the children who had visited the dentist, approximately 64% reported liking their visit, 11% didn't like their visit, and 12% were afraid. 90% of the children preferred their dentist to wear a white coat, while 40% preferred them to wear a mask and protective eye glasses as protective measures during treatment. When asked to choose between two pictures of different clinical settings, 63% of the children indicated that they preferred a decorated dental clinic over a plain clinic. Fear of local anesthesia and tooth extraction were the most common reasons cited for not liking dental treatment. CONCLUSIONS: Children have strong perceptions and preferences regarding their dentists. Data collected for this study can be used by dentists to improve delivery of care.

Oral midazolam premedication for children undergoing general anaesthesia for dental care.

Objectives. To assess the efficacy and safety of injectable midazolam administered orally in 3 different doses in children undergoing complete dental rehabilitation under GA. Subjects and Methods. 60 children aged 2-6 years were enrolled in the study. The children were randomly assigned to one of 3 groups and received orally 0.5, 0.75, or 1.0 mg/kg of injectable midazolam mixed with apple juice 30 minutes before separation from parents. The following measurements were assessed: patient's acceptance of the medication, reaction to separation from parents, sedation scores, and recovery conditions. Results. More children were comfortable with parent separation in the group that received the 1.0 mg/kg dose (90%) compared to the group that received the 0.75 mg/kg dose (75%) and the group that received the 0.5 mg/kg dose (55%). The number of children who had desirable sedation was similar in the 0.75 mg/kg and 1.0 mg/kg dose groups. Twenty five percent of the children in the group that received the 0.5 mg/kg dose did not allow venepuncture before induction of GA, and induction of GA was poor for 20% of the children in this group. An increasing number of children scored excellent in terms of ease of venepuncture in 0.75 mg/kg dose group (10%) and in the 1.0 mg/kg dose group (20%) and in terms of induction of GA, 25% and 35%, respectively. Recovery of spontaneous ventilation and extubation was delayed by over 15 minutes in 2 children in the 1.0 mg/kg dose group. Conclusion. The dose of 0.75 mg/kg of injectable midazolam given orally as premedication is acceptable, effective, and safe.

Dentists' attitudes and practices toward provision of orthodontic treatment for children with visual and hearing impairments.

The objective of this study was to determine differences in behavior and attitudes of dentists in Riyadh, Saudi Arabia, in providing orthodontic care for children who are sensory impaired. A self-administered questionnaire was sent to all dentists working in Riyadh to assess the following domains: personal characteristics of the dentists and their practices, provision of dental care for children who are visually-impaired (Vl) and/or hearing-impaired (HI), and their attitude toward providing orthodontic care for these children. Attitudes were measured on two scales and the overall score of these two scales represented each respondent's attitude. Thirty percent of the dentists provided dental care for children with VI and 45.3 percent did for children with HI. The provision of orthodontic care was significantly affected by the country in which the dentists had received their dental training, both for children with VI and HI (p < 0.01), and by number of years they had been in practice for children with VI (p < 0.05). Regression analysis showed that only the country of dental training significantly affected the dentist's attitude score. There were also significant variations in attitudes toward the provision of orthodontic treatment for children with sensory impairment (SI), influenced by dental training and experience. In practical terms, this means that improvement in attitudes needs to be initiated at the dental undergraduate level. Establishing global guidelines for the provision of orthodontic treatment for patients with sensory impairment is likely to assist both professionals and patients.