Cardiovascular Safety and Hemostatic Efficacy of Topical Epinephrine in Children Receiving Zirconia Crowns.

OBJECTIVE: The primary aim of this study was to determine the cardiovascular safety of topical racemic epinephrine pellets by measuring heart rate, systolic blood pressure, diastolic blood pressure, and mean arterial pressure in children receiving dental care under general anesthesia. The secondary aim was to assess clinical efficacy by measuring time to reach adequate hemostasis. METHODS: For this pilot study utilizing a split-mouth randomized design, 13 patients requiring prefabricated zirconia crowns on both primary maxillary first molars were recruited. Patients received continuous infusions of propofol and remifentanil with 50-70% inhaled nitrous oxide and oxygen. After randomization and tooth preparation, either saline pellets (control) or racemic epinephrine pellets (experimental) were applied directly to gingival tissue. Vital signs were recorded for 5 minutes. The procedure was repeated on the contralateral side using the alternative (control or experimental) treatment. RESULTS: Topical racemic epinephrine compared to saline produced a significantly larger decrease in mean diastolic blood pressure (-11.1% vs -3.9%; P < .01) and mean arterial pressure (-8.1% vs -2.1%; P < .01), although all noted decreases in cardiovascular variables were clinically insignificant. All experimental treatment teeth achieved adequate hemostasis after 2.2 minutes. Only 5 of the 13 control treatment teeth achieved adequate hemostasis during the 5-minute observation period (1.6 vs 4.2 minutes; P = .01). CONCLUSION: Overall, we conclude that use of topical racemic epinephrine pellets did not result in adverse cardiovascular effects and hemostasis was reached more quickly and predictably compared to saline pellets.

Temperament as a Predictor of Nitrous Oxide Inhalation Sedation Success.

Little is known about implications of temperament for children who receive nitrous oxide inhalation sedation (N2O/O2) for dental care. The aim of this study was to investigate whether child temperament is associated with success in N2O/O2. Child-caregiver dyads were enrolled from patients aged 36-95 months receiving dental care with N2O/O2 at a university-based pediatric dental clinic. To assess child temperament, 48 caregivers completed the Children's Behavior Questionnaire Short Form. Patient behavior was abstracted from Frankl scores recorded in the patient's chart. The overall behavioral failure rate was 15% (n = 7/48). There was no significant difference in sedation outcome associated with sex, health, insurance status, or complexity of treatment provided. Sedation outcome was significantly associated with the broad temperament domain of Effortful Control and its subscales Attentional Focusing and Inhibitory Control. The Negative Affectivity subscales of Frustration, Sadness, and Soothability and the Extraversion/Surgency subscales Activity and Impulsivity were also significantly associated with sedation outcome. The results of this study suggest that Effortful Control is associated with behavior during dental treatment with N2O/O2. The subscales of Attention Focusing, Inhibitory Control, Frustration, Fear, Sadness, Soothability, Activity, and Impulsivity may also be important determinants of child behavior during dental treatment.

Parent, Dentist, and Independent Rater Assessment of Child Distress During Preventive Dental Visits.

PURPOSE: Although typically not painful, preventive dental care can be distressing to young children. A greater understanding of how adults perceive child distress may enable clinicians to improve the patient/parent experience through alignment of values and facilitation of shared decision-making. The purpose of this study was to examine the association between parent, dentist, and independent observer (IO) ratings of child distress during preventive dental procedures. METHODS: Sixty-five children younger than three years were seen for preventive dental care at a university dental clinic. Parents, dentists, and an IO rated intensity of child distress during four phases of the dental visit: (1) pre-exam; (2) positioning; (3) prophylaxis/exam/fluoride; and (4) post-exam. RESULTS: The average age of the children was 24.4 months old (±7.2 SD). The prophylaxis/exam/fluoride phase was judged to be most distress inducing. Mean distress ratings for this phase were: 2.30 (parents); 2.47 (dentists); and 3.08 (IO), which was statistically significant (P=.04). The IO ratings were significantly different from parents (for three phases) and dentists (for one phase); no statistically significant differences were noted between parent and dentist ratings for any phase. CONCLUSIONS: There was a strong agreement between parents' and dentists' ratings of child distress during preventive dental procedures.

Dental stories for children with autism.

PURPOSE: To investigate caregivers' preference regarding dental stories to prepare children with autism for dental visits. METHODS: Caregivers of children with autism were allowed use of dental stories available via different media (paper, tablet computer, computer) and image types (comics or drawings, photographs, video). Caregivers completed pre- and postintervention surveys. Fisher's exact tests were used to determine associations between predictive factors and preferences. RESULTS: Forty initial and 16 follow-up surveys were completed. Subjects were primarily male (85%). Mean child age was 6.7 years. Nine (64%) caregivers found the dental story useful for themselves and their child. Two (14%) caregivers found the aid only helpful for themselves. Preferred media type was associated with language understanding (p = .038) and home media preference (p = .002). CONCLUSIONS: Practitioners should consider using dental stories to help prepare families and children for dental visits. Individual preferences for dental stories vary; using prior history can aid in selection.

Assessing Temperament as a Predictor of Oral Sedation Success Using the Children's Behavior Questionnaire Short Form.

PURPOSE: The purpose of this study was to investigate whether temperament, as measured by the Children's Behavior Questionnaire Short Form (CBQ-SF), was associated with success in oral sedation. METHODS: Child-caregiver dyads were enrolled from patients presenting for midazolam, meperidine, and hydroxyzine oral sedation. Children between 36 and 95 months of age, American Society of Anesthesiology (ASA) classification I or II, with diagnostic radiographs, whose parents believed he/she would swallow oral medications, were enrolled. To assess child temperament, caregivers completed the CBQ-SF. Behavior during sedation and overall sedation results were recorded using the Houpt Behavior Rating Scale. Failure was defined by Houpt overall ratings of fair or worse. The presence of disruptive behavior was also quantified. RESULTS: The sample population consisted of 61 patient-caregiver dyads. The overall sedation success rate was 87 percent (N equals 53). Disruptive behavior was present during 28 percent (N equals 17) of total cases. There was not a significant difference in failure rate or presence of disruptive behavior by age, sex, ASA status, insurance status, reason for sedation, or type of treatment provided. High impulsivity scores were significantly associated with disruptive behavior (P=.04). CONCLUSIONS: Impulsivity may be a determinant of a child's behavior during sedation.

Pediatric dental sedation: challenges and opportunities.

High levels of dental caries, challenging child behavior, and parent expectations support a need for sedation in pediatric dentistry. This paper reviews modern developments in pediatric sedation with a focus on implementing techniques to enhance success and patient safety. In recent years, sedation for dental procedures has been implicated in a disproportionate number of cases that resulted in death or permanent neurologic damage. The youngest children and those with more complicated medical backgrounds appear to be at greatest risk. To reduce complications, practitioners and regulatory bodies have supported a renewed focus on health care quality and safety. Implementation of high fidelity simulation training and improvements in patient monitoring, including end-tidal carbon dioxide, are becoming recognized as a new standard for sedated patients in dental offices and health care facilities. Safe and appropriate case selection and appropriate dosing for overweight children is also paramount. Oral sedation has been the mainstay of pediatric dental sedation; however, today practitioners are administering modern drugs in new ways with high levels of success. Employing contemporary transmucosal administration devices increases patient acceptance and sedation predictability. While recently there have been many positive developments in sedation technology, it is now thought that medications used in sedation and anesthesia may have adverse effects on the developing brain. The evidence for this is not definitive, but we suggest that practitioners recognize this developing area and counsel patients accordingly. Finally, there is a clear trend of increased use of ambulatory anesthesia services for pediatric dentistry. Today, parents and practitioners have become accustomed to children receiving general anesthesia in the outpatient setting. As a result of these changes, it is possible that dental providers will abandon the practice of personally administering large amounts of sedation to patients, and focus instead on careful case selection for lighter in-office sedation techniques.

Educational and therapeutic behavioral approaches to providing dental care for patients with Autism Spectrum Disorder.

PURPOSE: Autism Spectrum Disorder (ASD) is a condition which most dentists will encounter in their practices. Contemporary educational and behavioral approaches may facilitate successful dental care. METHODS: A literature review was conducted for relevant information on dental care for children with ASD. RESULTS: Educational principles used for children with ASD can be applied in the dental setting. Examples include: parent involvement in identifying strengths, sensitivities, and goal setting; using stories or video modeling in advance of the appointment; dividing dental treatment into sequential components; and modification of the environment to minimize sensory triggers. Patients with ASD are more capable of tolerating procedures that they are familiar with, and therefore should be exposed to new environments and stimuli in small incremental steps. CONCLUSIONS: By taking time to understand children with ASD as individuals and employing principles of learning, clinicians can provide high quality dental care for the majority of patients with ASD.

Assessing the effectiveness of text messages as appointment reminders in a pediatric dental setting.

BACKGROUND: Text messaging is a dominant form of communication in our society. However, little research has been conducted to evaluate its effectiveness as an appointment reminder in the dental setting. METHODS: From the patient pool of the pediatric dentistry clinic at the University of Washington, Seattle, the authors invited 543 caregiver/child dyads who met eligibility criteria to participate in this study. They randomly assigned 318 pairs (59 percent response) to receive a short message service (SMS) text message (n = 158) or a voice message (control group) (n = 160) as an appointment reminder. RESULTS: Younger caregivers were more likely to be nonattendees than were older caregivers (P = .02). Participants in the voice message group had a lower no-show attendance (8.2 percent) than did those in the text message group (17.7 percent) (P = .01). The unadjusted odds ratio (OR) for type of appointment reminder and no-show attendance was 2.41 (P = .01). After the authors adjusted for the caregiver's age, the OR was 2.12 (P = .04). CONCLUSIONS: SMS text messages were not as effective as voice reminders for patients in a dental school pediatric dentistry clinic. Future studies should investigate the effect of text message reminders when limited to patients who self-select that type of reminder and in patient populations outside the university setting. CLINICAL IMPLICATIONS: Text messaging may not be the preferable method of reminding patients about appointments in a university pediatric dental clinic.